Basic Information
| Provider Information | |||||||||
| NPI: | 1396738373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLINS | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | T. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3922 WOODLEY RD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436061130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192912121 | ||||||||
| FaxNumber: | 4194796017 | ||||||||
| Practice Location | |||||||||
| Address1: | 3922 WOODLEY RD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436061130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192912121 | ||||||||
| FaxNumber: | 4194796017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2005 | ||||||||
| LastUpdateDate: | 04/30/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35045187 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000000216338 | 01 | MI | ANTHEM | OTHER | 0633282 | 01 | OH | AETNA | OTHER | 3505802341 | 01 | MI | BCBS MI | OTHER | 12-03666 | 01 | MI | UHC | OTHER | 0524756 | 01 | OH | BCMH | OTHER | 000000141258 | 01 | OH | ANTHEM | OTHER | 00007 | 01 | OH | PHC | OTHER | 12-01285 | 01 | OH | UHC | OTHER | 370012693 | 01 | OH | RRMC | OTHER | 4002372 | 01 | MI | AETNA | OTHER | 0534756 | 05 | OH | MEDICAID |