Healthcare Provider Details

I. General information

NPI: 1023416849
Provider Name (Legal Business Name): PROMEDICA CENTRAL PHYSICIANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2014
Last Update Date: 12/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 ASHWOOD DR
TIFFIN OH
44883-1908
US

IV. Provider business mailing address

60 ASHWOOD DR
TIFFIN OH
44883-1908
US

V. Phone/Fax

Practice location:
  • Phone: 734-243-5300
  • Fax:
Mailing address:
  • Phone: 734-243-5300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateOH

VIII. Authorized Official

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