MEDICARE: PROMEDICA CENTRAL PHYSICIANS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1811189780
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROMEDICA CENTRAL PHYSICIANS, LLC

Provider Business Mailing Address
First Line	:	7140 PORT SYLVANIA DR
Second Line	:	SUITE 150
City	:	TOLEDO
State	:	OH
Zip	:	43617-1176
Country	:	US
Telephone Number	:	419-843-8170
Fax Number	:	419-843-1804

Provider Business Practice Location Address
First Line	:	7140 PORT SYLVANIA DR
Second Line	:	SUITE 150
City	:	TOLEDO
State	:	OH
Zip	:	43617-1176
Country	:	US
Telephone Number	:	419-843-8170
Fax Number	:	419-843-1804

Authorized Official
Title or Position	:	CREDENTIALING ASSISTANT
Name	:	KIMBERLY GOVAN
Credential	:
Telephone Number	:	419-824-7221

Provider Enumeration Date	:	08/15/2007
Last Update Date	:	08/15/2007

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