=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144296062
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIBERIU S. AVRAM M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2006
-----------------------------------------------------
Last Update Date | 04/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3715 AIRPORT HWY SUITE F
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43615-7173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-389-0492
-----------------------------------------------------
Fax | 419-381-0751
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 153 FOREST GLEN DR
-----------------------------------------------------
City | HOLLAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43528-9207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-450-0045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology
-----------------------------------------------------
License Number | 35087285
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology
-----------------------------------------------------
License Number | 01061540A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------