Basic Information
| Provider Information | |||||||||
| NPI: | 1861666141 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERNAL MEDICINE ASSOCIATES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SYCAMORE WOUND CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2110 LEITER RD | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453423598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373844838 | ||||||||
| FaxNumber: | 9373844845 | ||||||||
| Practice Location | |||||||||
| Address1: | 4000 MIAMISBURG CENTERVILLE RD | ||||||||
| Address2: | |||||||||
| City: | MIAMISBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453427615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373844329 | ||||||||
| FaxNumber: | 9373844853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2008 | ||||||||
| LastUpdateDate: | 10/30/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAIBACH | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF NETWORK CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 9375583222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 2461429 | 05 | OH | MEDICAID | 2963164 | 05 | OH | MEDICAID | 2884142 | 05 | OH | MEDICAID | 0559435 | 05 | OH | MEDICAID | 0707882 | 05 | OH | MEDICAID |