1417355223 NPI number — PROMEDICA CENTRAL PHYSICIANS LLC

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 1417355223 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:
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:
1417355223
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1180 N MONROE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48162-3190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-243-5300
Provider Business Mailing Address Fax Number:
734-243-3236

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1180 N MONROE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48162-3190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-243-5300
Provider Business Practice Location Address Fax Number:
734-243-3236
Provider Enumeration Date:
12/10/2014

Additional Information

Authorized Official

Authorized Official Last Name:
DYWER
Authorized Official First Name:
AMY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CREDENTIALING SUPERVISOR
Authorized Official Telephone Number:
419-824-7334

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207W00000X , 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)





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