Basic Information
| Provider Information | |||||||||
| NPI: | 1760722243 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF TOLEDO PHYSICIANS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UTP INFUSION CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3355 GLENDALE AVE | ||||||||
| Address2: | THIRD FLOOR | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436142426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193837100 | ||||||||
| FaxNumber: | 4193832000 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 CONFERENCE DR | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436148009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193836644 | ||||||||
| FaxNumber: | 4193836714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2013 | ||||||||
| LastUpdateDate: | 11/20/2018 | ||||||||
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| AuthorizedOfficialLastName: | HALL | ||||||||
| AuthorizedOfficialFirstName: | GAIL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 4193834025 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY OF TOLEDO PHYSICIANS CLINICAL FACULTY | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 2120903 | 05 | OH | MEDICAID |