Basic Information
| Provider Information | |||||||||
| NPI: | 1114926045 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAY | ||||||||
| FirstName: | LORRAINE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 8970 | ||||||||
| Address2: | 4334 SECOR ROAD | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436230970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194754449 | ||||||||
| FaxNumber: | 4195171399 | ||||||||
| Practice Location | |||||||||
| Address1: | 6629 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436171098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195171758 | ||||||||
| FaxNumber: | 4195171399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 02/21/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35049099 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0006X | 35.049099 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 12-02007 | 01 | OH | UHC | OTHER | 370020641 | 01 | OH | RRMC | OTHER | 4244898 | 01 | OH | AETNA | OTHER | 00415 | 01 | OH | PARAMOUNT | OTHER | 0516758 | 05 | OH | MEDICAID | 000000354761 | 01 | OH | ANTHEM | OTHER |