Provider Demographics
NPI:1831191444
Name:BACK, BILLY (MD)
Entity type:Individual
Prefix:DR
First Name:BILLY
Middle Name:
Last Name:BACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:OH
Mailing Address - Zip Code:44837-1030
Mailing Address - Country:US
Mailing Address - Phone:419-752-1811
Mailing Address - Fax:419-752-2145
Practice Address - Street 1:65 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:OH
Practice Address - Zip Code:44837-1030
Practice Address - Country:US
Practice Address - Phone:419-752-1811
Practice Address - Fax:419-752-2145
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35078984207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH110219196OtherRR MEDICARE
OH2227781Medicaid
OH2227781Medicaid
OHBA4044931Medicare ID - Type Unspecified