Provider Demographics
NPI: | 1942296033 |
---|---|
Name: | UNIVERSITY OF TOLEDO PHYSICIANS LLC |
Entity Type: | Organization |
Organization Name: | UNIVERSITY OF TOLEDO PHYSICIANS LLC |
Other - Org Name: | |
Other - Org Type: | |
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: | |
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: | 419-383-6235 |
Practice Address - Street 1: | 3000 ARLINGTON AVE |
Practice Address - Street 2: | |
Practice Address - City: | TOLEDO |
Practice Address - State: | OH |
Practice Address - Zip Code: | 43614-2595 |
Practice Address - Country: | US |
Practice Address - Phone: | 419-383-5000 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | UNIVERSITY OF TOLEDO PHYSICIANS CLINICAL FACULTY INC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2005-09-23 |
Last Update Date: | 2024-02-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | 103TC0700X, 207L00000X, 207R00000X, 207RR0500X, 207X00000X, 207ZP0102X, 208000000X, 2084P0800X, 2085R0202X, 208600000X, 208800000X | |
207RC0000X, 207RP1001X, 207V00000X, 208100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
No | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology | Group - Multi-Specialty | |
No | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | Group - Multi-Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 207ZP0102X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | Group - Multi-Specialty |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Group - Multi-Specialty | |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 2120903 | Medicaid | |
OH | 2120903 | Medicaid | |
OH | CI0002 | Other | RR MEDICARE |
6105930001 | Medicare NSC | ||
OH | 9301489 | Medicare PIN |