Provider Demographics
NPI:1831526730
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 SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DWYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-824-7334
Mailing Address - Street 1:5308 HARROUN RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2114
Mailing Address - Country:US
Mailing Address - Phone:419-824-6559
Mailing Address - Fax:419-824-0343
Practice Address - Street 1:5308 HARROUN RD
Practice Address - Street 2:SUITE 180
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2114
Practice Address - Country:US
Practice Address - Phone:419-824-6559
Practice Address - Fax:419-824-0343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-09
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH208600000X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty