Basic Information
| Provider Information | |||||||||
| NPI: | 1659311405 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL COLLEGE OF OHIO PHYSICIANS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MCO FAMILY PRACTICE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 GARDEN LAKE PKWY | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436142779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193835500 | ||||||||
| FaxNumber: | 4193835575 | ||||||||
| Practice Location | |||||||||
| Address1: | 1015 GARDEN LAKE PKWY | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436142779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193835500 | ||||||||
| FaxNumber: | 4193835575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RASSEL | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DATA ENTRY SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 4193835504 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2554847 | 05 | OH | MEDICAID |