Healthcare Provider Details

I. General information

NPI: 1063691269
Provider Name (Legal Business Name): PROMEDICA CENTRAL PHYSCIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2007
Last Update Date: 02/05/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3140 W CENTRAL AVE
TOLEDO OH
43606-2920
US

IV. Provider business mailing address

3140 W CENTRAL AVE
TOLEDO OH
43606-2920
US

V. Phone/Fax

Practice location:
  • Phone: 419-537-5111
  • Fax: 419-537-5131
Mailing address:
  • Phone: 419-537-5111
  • Fax: 419-537-5131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number
License Number State

VIII. Authorized Official

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