1457630105 NPI number — PROMEDICA NORTHWEST OHIO CARDIOLOGY CONSULTANTS, LLC

Table of content: (NPI 1457630105)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457630105 NPI number — PROMEDICA NORTHWEST OHIO CARDIOLOGY CONSULTANTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROMEDICA NORTHWEST OHIO CARDIOLOGY CONSULTANTS, 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:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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NPI Number Information

NPI Number:
1457630105
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
734 S SHOOP AVE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
WAUSEON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43567-1707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-337-9995
Provider Business Mailing Address Fax Number:
419-337-9994

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
734 S SHOOP AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
WAUSEON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43567-1707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-337-9995
Provider Business Practice Location Address Fax Number:
419-337-9994
Provider Enumeration Date:
08/12/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BAHNSEN
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: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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