Provider Demographics
NPI:1659968014
Name:ROY, ETHAN THOMAS
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:THOMAS
Last Name:ROY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 1/2 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-3506
Mailing Address - Country:US
Mailing Address - Phone:937-403-6773
Mailing Address - Fax:
Practice Address - Street 1:3590 US HIGHWAY 23
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-8341
Practice Address - Country:US
Practice Address - Phone:740-663-7386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0098268Medicaid