Basic Information
| Provider Information | |||||||||
| NPI: | 1215240676 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF TOLEDO PHYSICIANS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UTP SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3355 GLENDALE AVE | ||||||||
| Address2: | THIRD FLOOR | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436142426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193837100 | ||||||||
| FaxNumber: | 4193832000 | ||||||||
| Practice Location | |||||||||
| Address1: | 3000 ARLINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436142595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193833761 | ||||||||
| FaxNumber: | 4193836170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2010 | ||||||||
| LastUpdateDate: | 06/14/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRICKMAN | ||||||||
| AuthorizedOfficialFirstName: | KRIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | UTP PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4193837100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF TOLEDO PHYSICIANS CLINICAL FACULTY | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0329226 | 05 | OH | MEDICAID |