Provider Demographics
NPI:1659311405
Name:MEDICAL COLLEGE OF OHIO PHYSICIANS, LLC
Entity Type:Organization
Organization Name:MEDICAL COLLEGE OF OHIO PHYSICIANS, LLC
Other - Org Name:MCO FAMILY PRACTICE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DATA ENTRY SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:RASSEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-383-5504
Mailing Address - Street 1:1015 GARDEN LAKE PKWY
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-2779
Mailing Address - Country:US
Mailing Address - Phone:419-383-5500
Mailing Address - Fax:419-383-5575
Practice Address - Street 1:1015 GARDEN LAKE PKWY
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2779
Practice Address - Country:US
Practice Address - Phone:419-383-5500
Practice Address - Fax:419-383-5575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2554847Medicaid
OH9155071Medicare ID - Type Unspecified