1194078055 NPI number — PROMEDICA MONROE PHYSICIANS PLLC

Table of content: (NPI 1194078055)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194078055 NPI number — PROMEDICA MONROE PHYSICIANS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROMEDICA MONROE PHYSICIANS PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1194078055
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 MADISON AVE
Provider Second Line Business Mailing Address:
MSC-S38805
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
844-373-0871
Provider Business Mailing Address Fax Number:
419-885-3921

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MADISON AVE
Provider Second Line Business Practice Location Address:
MSC-S38805
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-373-0871
Provider Business Practice Location Address Fax Number:
419-885-3921
Provider Enumeration Date:
10/17/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KNUEVEN
Authorized Official First Name:
KRISTIN
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SUPERVISOR
Authorized Official Telephone Number:
567-585-1969

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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