Provider Demographics
NPI:1134112329
Name:INTERNAL MEDICINE ASSOCIATES OF CLINTON COUNTY INC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE ASSOCIATES OF CLINTON COUNTY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:EDMUND
Authorized Official - Last Name:STALEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-382-5030
Mailing Address - Street 1:891 W LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-2118
Mailing Address - Country:US
Mailing Address - Phone:937-382-5030
Mailing Address - Fax:937-655-8390
Practice Address - Street 1:891 W LOCUST ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2118
Practice Address - Country:US
Practice Address - Phone:937-382-5030
Practice Address - Fax:937-655-8390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0385373Medicaid
OHIN9287061OtherMEDICARE GROUP