Healthcare Provider Details

I. General information

NPI: 1295879716
Provider Name (Legal Business Name): PROMEDICA CENTRAL PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 BEAVER CREEK CIR SUITE 130
MAUMEE OH
43537-1734
US

IV. Provider business mailing address

650 BEAVER CREEK CIR SUITE 130
MAUMEE OH
43537-1734
US

V. Phone/Fax

Practice location:
  • Phone: 419-891-6262
  • Fax: 419-893-1196
Mailing address:
  • Phone: 419-891-6262
  • Fax: 419-893-1196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: KENYA DIXON
Title or Position: CREDENTIALING ASSISTANT
Credential:
Phone: 419-824-7288