Healthcare Provider Details

I. General information

NPI: 1053455170
Provider Name (Legal Business Name): PROMEDICA CENTRAL PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 BRIGHAM DR SUITE 200
PERRYSBURG OH
43551-7114
US

IV. Provider business mailing address

1601 BRIGHAM DR SUITE 200
PERRYSBURG OH
43551-7114
US

V. Phone/Fax

Practice location:
  • Phone: 419-872-7700
  • Fax: 419-874-0196
Mailing address:
  • Phone: 419-872-7700
  • Fax: 419-874-0196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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