Provider Demographics
NPI:1548304074
Name:PROMEDICA CENTRAL PHYSICIANS, LLC
Entity type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIANS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:KENYA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-824-7288
Mailing Address - Street 1:2865 N REYNOLDS RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-2068
Mailing Address - Country:US
Mailing Address - Phone:419-578-7036
Mailing Address - Fax:419-537-5597
Practice Address - Street 1:2865 N REYNOLDS RD
Practice Address - Street 2:SUITE 130
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-2068
Practice Address - Country:US
Practice Address - Phone:419-578-7036
Practice Address - Fax:419-537-5597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-17
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4036950013Medicare NSC
OHPR9305778Medicare ID - Type Unspecified