Healthcare Provider Details

I. General information

NPI: 1467731117
Provider Name (Legal Business Name): PROMEDICA NORTHWEST OHIO CARDIOLOGY CONSULTANTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2011
Last Update Date: 08/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 RIVERSIDE AVE SUITE 106
ADRIAN MI
49221-1476
US

IV. Provider business mailing address

770 RIVERSIDE AVE SUITE 106
ADRIAN MI
49221-1476
US

V. Phone/Fax

Practice location:
  • Phone: 517-266-0525
  • Fax: 517-266-0956
Mailing address:
  • Phone: 517-266-0525
  • Fax: 517-266-0956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: AMY L BAHNSEN
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 419-824-7334