Provider Demographics
NPI:1689665044
Name:HARTVILLE INTERNAL MEDICINE PA
Entity Type:Organization
Organization Name:HARTVILLE INTERNAL MEDICINE PA
Other - Org Name:MINERVA MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMIN
Authorized Official - Middle Name:YOUSSEF
Authorized Official - Last Name:KHALIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-877-9388
Mailing Address - Street 1:200 CAROLYN CT
Mailing Address - Street 2:
Mailing Address - City:MINERVA
Mailing Address - State:OH
Mailing Address - Zip Code:44657-8758
Mailing Address - Country:US
Mailing Address - Phone:330-868-4184
Mailing Address - Fax:330-488-2907
Practice Address - Street 1:200 CAROLYN CT
Practice Address - Street 2:
Practice Address - City:MINERVA
Practice Address - State:OH
Practice Address - Zip Code:44657-8758
Practice Address - Country:US
Practice Address - Phone:330-868-4184
Practice Address - Fax:330-488-2907
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HARTVILLE INTERNAL MEDICINE PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-03
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000342549OtherANTHEM
OH2535742Medicaid
OH2535742Medicaid
OH000000342549OtherANTHEM
OHMI9318532Medicare PIN
OH000000342549OtherANTHEM