Basic Information
Provider Information | |||||||||
NPI: | 1720145899 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMPREHENSIVE FAMILY PRACTICE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4805 SUDER AVE | ||||||||
Address2: | SUITE A | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436111800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4197261585 | ||||||||
FaxNumber: | 4197260381 | ||||||||
Practice Location | |||||||||
Address1: | 4805 SUDER AVE | ||||||||
Address2: | SUITE A | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436111800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4197261585 | ||||||||
FaxNumber: | 4197260381 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/02/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NEVERAUSKAS | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | PRANAS | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT AND SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 4197261585 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.O | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34006654 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.