Provider Demographics
NPI:1700842796
Name:TOLEDO CLINIC PLLC
Entity type:Organization
Organization Name:TOLEDO CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:D
Authorized Official - Last Name:PENIX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-214-4214
Mailing Address - Street 1:4235 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7301 SECOR RD
Practice Address - Street 2:
Practice Address - City:LAMBERTVILLE
Practice Address - State:MI
Practice Address - Zip Code:48144-9737
Practice Address - Country:US
Practice Address - Phone:419-479-5795
Practice Address - Fax:419-479-5797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0080302Medicaid