Healthcare Provider Details

I. General information

NPI: 1588091599
Provider Name (Legal Business Name): PROMEDICA CENTRAL PHYSICIANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2013
Last Update Date: 10/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2751 BAY PARK DR SUITE 202
OREGON OH
43616-4921
US

IV. Provider business mailing address

2751 BAY PARK DR SUITE 202
OREGON OH
43616-4921
US

V. Phone/Fax

Practice location:
  • Phone: 419-690-7550
  • Fax: 419-697-7919
Mailing address:
  • Phone: 419-690-7550
  • Fax: 419-697-7919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateOH

VIII. Authorized Official

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