Basic Information
| Provider Information | |||||||||
| NPI: | 1720177314 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENDOCRINE & DIABETES CARE CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 W CENTRAL AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195375111 | ||||||||
| FaxNumber: | 4195375131 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 W CENTRAL AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195375111 | ||||||||
| FaxNumber: | 4195375131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 10/22/2019 | ||||||||
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| AuthorizedOfficialLastName: | BEHAM | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4195375111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 000000203474 | 01 | OH | ANTHEM | OTHER | 2267452 | 05 | OH | MEDICAID | CH8143 | 01 | OH | MEDICARE RR NUMBER | OTHER |