=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457311060
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST TOLEDO GENERAL SURGEONS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2109 HUGHES DRIVE SUITE 220
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-291-5150
-----------------------------------------------------
Fax | 419-479-6173
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2109 HUGHES DRIVE SUITE 220
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-291-5150
-----------------------------------------------------
Fax | 419-479-6173
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | PETER M DIZAD
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 419-291-5150
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------