Provider Demographics
NPI:1811951452
Name:TOLEDO COMMUNITY LITHOTRIPTER CORP.
Entity type:Organization
Organization Name:TOLEDO COMMUNITY LITHOTRIPTER CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:G.
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:SEAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-725-4400
Mailing Address - Street 1:3158 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-2920
Mailing Address - Country:US
Mailing Address - Phone:419-531-3538
Mailing Address - Fax:419-531-2807
Practice Address - Street 1:3158 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-2920
Practice Address - Country:US
Practice Address - Phone:419-531-3538
Practice Address - Fax:419-531-2807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH417261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2124675OtherAETNA
604727OtherBUCKEYE COMM. HEALTH PLAN
01767OtherPARAMOUNT
156605OtherANTHEM
OH0986054Medicaid
3610521OtherMMOH
OH3610521Medicare ID - Type Unspecified