Healthcare Provider Details

I. General information

NPI: 1891076899
Provider Name (Legal Business Name): PROMEDICA CENTRAL PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2011
Last Update Date: 09/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2109 HUGHES DR SUITE 760
TOLEDO OH
43606-3856
US

IV. Provider business mailing address

2109 HUGHES DR SUITE 760
TOLEDO OH
43606-3856
US

V. Phone/Fax

Practice location:
  • Phone: 419-479-2676
  • Fax: 419-479-2696
Mailing address:
  • Phone: 419-479-2676
  • Fax: 419-479-2696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

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