Healthcare Provider Details

I. General information

NPI: 1023865730
Provider Name (Legal Business Name): PROMEDEUS MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2024
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 S ASHLAND AVE
LEXINGTON KY
40502-1728
US

IV. Provider business mailing address

3150 CUSTER DR STE 101
LEXINGTON KY
40517-4010
US

V. Phone/Fax

Practice location:
  • Phone: 956-497-4285
  • Fax:
Mailing address:
  • Phone: 859-537-8419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. JESUS TOVAR
Title or Position: MEMBER
Credential: MD
Phone: 956-497-4285