MEDICARE: DORRENCE CONEY TALBUT MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	3502 0459T	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	448094	OTHER	OH	WORKERS COMP
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558360545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DORRENCE CONEY TALBUT MD

Provider Business Mailing Address
First Line	:	5757 MONCLOVA RD
Second Line	:	#2
City	:	MAUMEE
State	:	OH
Zip	:	43537-1863
Country	:	US
Telephone Number	:	419-893-7607
Fax Number	:	419-893-7608

Provider Business Practice Location Address
First Line	:	5757 MONCLOVA RD
Second Line	:	#2
City	:	MAUMEE
State	:	OH
Zip	:	43537-1863
Country	:	US
Telephone Number	:	419-893-7607
Fax Number	:	419-893-7608

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	07/08/2007

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