Healthcare Provider Details

I. General information

NPI: 1366795221
Provider Name (Legal Business Name): PROMEDICA GENITO-URINARY SURGEONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2012
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 W CENTRAL AVE
TOLEDO OH
43606-3834
US

IV. Provider business mailing address

100 MADISON AVE MSC-S38805
TOLEDO OH
43604
US

V. Phone/Fax

Practice location:
  • Phone: 419-531-8558
  • Fax: 419-531-8798
Mailing address:
  • Phone: 844-373-0871
  • Fax: 419-885-3921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateOH
# 5
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number StateOH

VIII. Authorized Official

Name: KRISTIN KNUEVEN
Title or Position: SUPERVISOR
Credential:
Phone: 567-585-1969