Provider Demographics
NPI:1871798413
Name:TROY INTERNAL MEDICINE, INC.
Entity type:Organization
Organization Name:TROY INTERNAL MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:NICKRAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-339-3838
Mailing Address - Street 1:530 CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-2718
Mailing Address - Country:US
Mailing Address - Phone:937-339-3838
Mailing Address - Fax:937-335-1232
Practice Address - Street 1:530 CRESCENT DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2718
Practice Address - Country:US
Practice Address - Phone:937-339-3838
Practice Address - Fax:937-335-1232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35037618N207R00000X
OH35036285N207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0212442Medicaid
OH9912442Medicare ID - Type Unspecified