Provider Demographics
NPI:1548403504
Name:UNIVERSITY OF TOLEDO PHYSICIANS, LLC
Entity Type:Organization
Organization Name:UNIVERSITY OF TOLEDO PHYSICIANS, LLC
Other - Org Name:UTP STUDENT SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR, MEDICAL STAFF SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:BS, CPCS
Authorized Official - Phone:419-383-5330
Mailing Address - Street 1:4510 DORR ST # MS 840
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-4040
Mailing Address - Country:US
Mailing Address - Phone:419-383-5330
Mailing Address - Fax:419-383-2000
Practice Address - Street 1:2801 W BANCROFT ST
Practice Address - Street 2:STUDENT SERVICES
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3328
Practice Address - Country:US
Practice Address - Phone:419-530-3451
Practice Address - Fax:419-530-3499
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF TOLEDO PHYSICIANS CLINICAL FACULTY INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-07
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076864207Q00000X
OH35061999207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2120903Medicaid
9301489Medicare PIN