1902881824 NPI number — PROMEDICA CONTINUING CARE SERVICES CORP

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 1902881824 NPI number — PROMEDICA CONTINUING CARE SERVICES CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROMEDICA CONTINUING CARE SERVICES CORP
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:
1902881824
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1801 RICHARDS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43607-1037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-469-3780
Provider Business Mailing Address Fax Number:
419-469-3781

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
770 RIVERSIDE AVE
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
ADRIAN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49221-1476
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-266-2568
Provider Business Practice Location Address Fax Number:
517-266-1036
Provider Enumeration Date:
12/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERTS
Authorized Official First Name:
GLADEEN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
419-469-3780

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 139856 . This is a "CARECHOICES OF MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 10133 . This is a "PARAMOUNT HEALTH CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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