Provider Demographics
NPI:1861517211
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 SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-824-7221
Mailing Address - Street 1:2121 HUGHES DR
Mailing Address - Street 2:SUITE 710
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3845
Mailing Address - Country:US
Mailing Address - Phone:419-291-3858
Mailing Address - Fax:419-480-8701
Practice Address - Street 1:2121 HUGHES DR
Practice Address - Street 2:SUITE 710
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3845
Practice Address - Country:US
Practice Address - Phone:419-291-3858
Practice Address - Fax:419-480-8701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0999273Medicaid
OH=========-41OtherBWC
OH=========-41OtherBWC