Basic Information
| Provider Information | |||||||||
| NPI: | 1609963370 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACINO | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3140 W SYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436134133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198245063 | ||||||||
| FaxNumber: | 4198240216 | ||||||||
| Practice Location | |||||||||
| Address1: | 3140 W SYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436134133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198245063 | ||||||||
| FaxNumber: | 4198240216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 2638186 | 05 | OH | MEDICAID | 203316143002 | 01 | OH | MEDICAL MUTUAL OF OHIO | OTHER |