Provider Demographics
NPI:1053532390
Name:CLINTON ANESTHESIA ASSOCIATES INC.
Entity type:Organization
Organization Name:CLINTON ANESTHESIA ASSOCIATES INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:HORN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-382-1864
Mailing Address - Street 1:807 W MAIN ST
Mailing Address - Street 2:P.O. BOX 868
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-2128
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35 051308174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0589635Medicaid
OH0589635Medicaid