Provider Demographics
NPI:1790755841
Name:ANCILLARY SERVICES OF MIDDLETOWN
Entity Type:Organization
Organization Name:ANCILLARY SERVICES OF MIDDLETOWN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-291-7850
Mailing Address - Street 1:PO BOX 632412
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-2412
Mailing Address - Country:US
Mailing Address - Phone:800-742-2368
Mailing Address - Fax:937-291-2962
Practice Address - Street 1:105 MCKNIGHT DR
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-4838
Practice Address - Country:US
Practice Address - Phone:800-742-2368
Practice Address - Fax:937-291-2962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0521126Medicaid
OH0521126Medicaid