1770624181 NPI number — PROMEDICA CENTRAL PHYSICIANS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770624181 NPI number — PROMEDICA CENTRAL PHYSICIANS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROMEDICA CENTRAL PHYSICIANS
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:
6
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:
1770624181
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3909 WOODLEY RD
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43606-1169
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-291-2670
Provider Business Mailing Address Fax Number:
419-479-6999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3909 WOODLEY RD
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43606-1169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-291-2670
Provider Business Practice Location Address Fax Number:
419-479-6999
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOVAN
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRACTICE SERVICES SUPERVISOR
Authorized Official Telephone Number:
419-824-7221

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , 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)





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