Healthcare Provider Details

I. General information

NPI: 1366721920
Provider Name (Legal Business Name): PROMEDICA CENTRAL PHYSICIANS
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

5308 HARROUN RD SUITE 160
SYLVANIA OH
43560-2114
US

IV. Provider business mailing address

5308 HARROUN RD SUITE 160
SYLVANIA OH
43560-2114
US

V. Phone/Fax

Practice location:
  • Phone: 419-824-5668
  • Fax: 419-885-6919
Mailing address:
  • Phone: 419-824-5668
  • Fax: 419-885-6919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number
License Number State

VIII. Authorized Official

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