Basic Information
| Provider Information | |||||||||
| NPI: | 1831184720 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAIS | ||||||||
| FirstName: | THEODOR | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3355 GLENDALE AVE | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436142426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193837146 | ||||||||
| FaxNumber: | 4193832050 | ||||||||
| Practice Location | |||||||||
| Address1: | 3130 GLENDALE AVE | ||||||||
| Address2: | KOBACKER CENTER | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436145811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193833815 | ||||||||
| FaxNumber: | 4193833098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 10/13/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084F0202X | 35076784 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Forensic Psychiatry | 2084P0800X | 35076784 | OH | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 35076784 | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 2144183 | 05 | OH | MEDICAID |