Healthcare Provider Details

I. General information

NPI: 1285826156
Provider Name (Legal Business Name): PROMEDICA CENTRAL PHYSICIANS,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 08/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 BRIGHAM DR SUITE 250A
PERRYSBURG OH
43551-7114
US

IV. Provider business mailing address

1601 BRIGHAM DR SUITE 250A
PERRYSBURG OH
43551-7114
US

V. Phone/Fax

Practice location:
  • Phone: 419-872-7760
  • Fax: 419-874-8657
Mailing address:
  • Phone: 419-872-7760
  • Fax: 419-874-8657

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number34007277
License Number StateOH

VIII. Authorized Official

Name: KIMBERLY GOVAN
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 419-824-7221