Provider Demographics
NPI:1861666141
Name:INTERNAL MEDICINE ASSOCIATES, INC.
Entity Type:Organization
Organization Name:INTERNAL MEDICINE ASSOCIATES, INC.
Other - Org Name:SYCAMORE WOUND CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF NETWORK CONTRACTING
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAIBACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-558-3222
Mailing Address - Street 1:2110 LEITER RD
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3598
Mailing Address - Country:US
Mailing Address - Phone:937-384-4838
Mailing Address - Fax:937-384-4845
Practice Address - Street 1:4000 MIAMISBURG CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-7615
Practice Address - Country:US
Practice Address - Phone:937-384-4329
Practice Address - Fax:937-384-4853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2461429Medicaid
OH2963164Medicaid
OH2884142Medicaid
OH0559435Medicaid
OH0707882Medicaid
OH=========OtherTAX ID #
OH2963164Medicaid
OH=========OtherTAX ID #
OH2884142Medicaid
OHRA0550034Medicare PIN