Provider Demographics
NPI:1891834594
Name:HORN, CONNIE S (MD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:S
Last Name:HORN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 868
Mailing Address - Street 2:807 W MAIN ST
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-0868
Mailing Address - Country:US
Mailing Address - Phone:937-382-1864
Mailing Address - Fax:937-382-8917
Practice Address - Street 1:807 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2128
Practice Address - Country:US
Practice Address - Phone:937-382-1864
Practice Address - Fax:937-382-8917
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35051308207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000012224OtherANTHEM
OH0606562Medicaid
OH311127991OtherTAX ID
A82172Medicare UPIN
OH000000012224OtherANTHEM