Healthcare Provider Details

I. General information

NPI: 1659676708
Provider Name (Legal Business Name): PROMEDICA MONROE CARDIOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2011
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 N MACOMB ST SUITE 429
MONROE MI
48162-2900
US

IV. Provider business mailing address

100 MADISON AVE MSC-S38805
TOLEDO OH
43604
US

V. Phone/Fax

Practice location:
  • Phone: 734-242-7060
  • Fax: 734-241-7580
Mailing address:
  • Phone: 844-373-0871
  • Fax: 419-885-3921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: TANYA WINES
Title or Position: DIRECTOR, SYSTEM CREDENTIALING
Credential:
Phone: 567-585-0422