1669713194 NPI number — THOMAS SANDY III CPO

Table of content: THOMAS SANDY III CPO (NPI 1669713194)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669713194 NPI number — THOMAS SANDY III CPO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANDY
Provider First Name:
THOMAS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
CPO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669713194
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3435 N HOLLAND SYLVANIA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43615-1411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-841-9852
Provider Business Mailing Address Fax Number:
419-843-2727

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3435 N HOLLAND SYLVANIA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43615-1411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-841-9852
Provider Business Practice Location Address Fax Number:
419-843-2727
Provider Enumeration Date:
03/07/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 222Z00000X , with the licence number:  LPO234 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 224P00000X , with the licence number: LPO234 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2225121 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".