Healthcare Provider Details

I. General information

NPI: 1720367477
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

2702 NAVARRE AVE SUITE 310
OREGON OH
43616-3223
US

IV. Provider business mailing address

2702 NAVARRE AVE SUITE 310
OREGON OH
43616-3223
US

V. Phone/Fax

Practice location:
  • Phone: 419-697-0569
  • Fax: 419-691-0314
Mailing address:
  • Phone: 419-697-0569
  • Fax: 419-691-0314

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