Provider Demographics
NPI:1518908698
Name:CANTON INTERNAL MEDICINE ASSOCIATES INCE
Entity Type:Organization
Organization Name:CANTON INTERNAL MEDICINE ASSOCIATES INCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE CLAIMS PROCESSOR
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DIEHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-833-5692
Mailing Address - Street 1:4076 HOLIDAY ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718
Mailing Address - Country:US
Mailing Address - Phone:330-492-3738
Mailing Address - Fax:330-492-5640
Practice Address - Street 1:4076 HOLIDAY ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718
Practice Address - Country:US
Practice Address - Phone:330-492-3738
Practice Address - Fax:330-492-5640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH35060119207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0792898Medicaid
OH0792898Medicaid
OHCA9337611Medicare ID - Type Unspecified