1992820302 NPI number — PROMEDICA CENTRAL PHYSICIANS, LLC

Table of content: (NPI 1992820302)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992820302 NPI number — PROMEDICA CENTRAL PHYSICIANS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROMEDICA CENTRAL PHYSICIANS, LLC
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:
CENTER FOR HEALTH SERVICES
Provider Other Organization Name Type Code:
3
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:
1992820302
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:
5855 MONROE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYLVANIA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43560-2269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-824-7221
Provider Business Mailing Address Fax Number:
419-824-7359

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2150 W CENTRAL AVE
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:
43606-3846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-291-8720
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOVAN
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
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: "X" .
  • Taxonomy code: 207R00000X , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207V00000X , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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