Provider Demographics
NPI:1114926045
Name:FAY, LORRAINE M (MD)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:M
Last Name:FAY
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:P.O. BOX 8970
Mailing Address - Street 2:4334 SECOR ROAD
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-0970
Mailing Address - Country:US
Mailing Address - Phone:419-475-4449
Mailing Address - Fax:419-517-1399
Practice Address - Street 1:6629 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-1098
Practice Address - Country:US
Practice Address - Phone:419-517-1758
Practice Address - Fax:419-517-1399
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35049099208000000X
OH35.0490992080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH12-02007OtherUHC
OH370020641OtherRRMC
OH4244898OtherAETNA
OH00415OtherPARAMOUNT
OH0516758Medicaid
OH000000354761OtherANTHEM
OH00415OtherPARAMOUNT
OH0516758Medicaid