Healthcare Provider Details

I. General information

NPI: 1548304074
Provider Name (Legal Business Name): PROMEDICA CENTRAL PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2007
Last Update Date: 02/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 N REYNOLDS RD SUITE 130
TOLEDO OH
43615-2068
US

IV. Provider business mailing address

2865 N REYNOLDS RD SUITE 130
TOLEDO OH
43615-2068
US

V. Phone/Fax

Practice location:
  • Phone: 419-578-7036
  • Fax: 419-537-5597
Mailing address:
  • Phone: 419-578-7036
  • Fax: 419-537-5597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: KENYA DIXON
Title or Position: CREDENTIALING ASSISTANT
Credential:
Phone: 419-824-7288