Provider Demographics
NPI:1932351483
Name:BACK, PATRICIA ANN (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:BACK
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 1:3130 N COUNTY ROAD 25A
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-1337
Mailing Address - Country:US
Mailing Address - Phone:937-440-4466
Mailing Address - Fax:937-440-4470
Practice Address - Street 1:30 E APPLE ST
Practice Address - Street 2:STE 6250
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2939
Practice Address - Country:US
Practice Address - Phone:937-208-8394
Practice Address - Fax:937-208-8388
Is Sole Proprietor?:No
Enumeration Date:2008-10-15
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10024926207Q00000X
NY250483-1207Q00000X
KY51286208M00000X
OH35-092581207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2966278Medicaid
OHH003634Medicare PIN
OH2033461Medicare PIN