Healthcare Provider Details

I. General information

NPI: 1043270150
Provider Name (Legal Business Name): PROMEDICA CENTRAL PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MADISON AVE MSC-S38805
TOLEDO OH
43604-1531
US

IV. Provider business mailing address

100 MADISON AVE MSC-S38805
TOLEDO OH
43604-1531
US

V. Phone/Fax

Practice location:
  • Phone: 567-585-1964
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number StateOH
# 7
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number StateMI
# 8
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateOH
# 9
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number StateMI
# 10
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number StateOH
# 11
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateOH
# 12
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StateMI
# 13
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateOH
# 14
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateOH
# 15
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateOH

VIII. Authorized Official

Name: TANYA WINES
Title or Position: DIRECTOR, CREDENTIALING
Credential:
Phone: 567-585-0422