Healthcare Provider Details

I. General information

NPI: 1417355223
Provider Name (Legal Business Name): PROMEDICA CENTRAL PHYSICIANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2014
Last Update Date: 12/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 N MONROE ST
MONROE MI
48162-3190
US

IV. Provider business mailing address

1180 N MONROE ST
MONROE MI
48162-3190
US

V. Phone/Fax

Practice location:
  • Phone: 734-243-5300
  • Fax: 734-243-3236
Mailing address:
  • Phone: 734-243-5300
  • Fax: 734-243-3236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateMI

VIII. Authorized Official

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