Basic Information
| Provider Information | |||||||||
| NPI: | 1457311060 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST TOLEDO GENERAL SURGEONS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2109 HUGHES DRIVE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192915150 | ||||||||
| FaxNumber: | 4194796173 | ||||||||
| Practice Location | |||||||||
| Address1: | 2109 HUGHES DRIVE | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192915150 | ||||||||
| FaxNumber: | 4194796173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DIZAD | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4192915150 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 0666775 | 05 | OH | MEDICAID |