Basic Information
| Provider Information | |||||||||
| NPI: | 1023562279 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STAY HOME I WILL, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CONCIERGE CONNECTED CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2230 W LASKEY RD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436133543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192141213 | ||||||||
| FaxNumber: | 4192140783 | ||||||||
| Practice Location | |||||||||
| Address1: | 2230 W LASKEY RD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436133543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192141213 | ||||||||
| FaxNumber: | 4192140783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2016 | ||||||||
| LastUpdateDate: | 09/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GOKULA | ||||||||
| AuthorizedOfficialFirstName: | RADHARAMANAMURTHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 4192141213 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MD,CMD,DIPABLM | ||||||||
| NPICertificationDate: | 09/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35-089833 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.