Healthcare Provider Details

I. General information

NPI: 1144365669
Provider Name (Legal Business Name): PROMEDICA CENTRAL PHYSICIANS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2109 HUGHES DR SUITE 860
TOLEDO OH
43606-3856
US

IV. Provider business mailing address

2109 HUGHES DR SUITE 860
TOLEDO OH
43606-3856
US

V. Phone/Fax

Practice location:
  • Phone: 419-291-7010
  • Fax: 419-479-6917
Mailing address:
  • Phone: 419-291-7010
  • Fax: 419-479-6917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number StateOH

VIII. Authorized Official

Name: KIMBERLY GOVAN
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 419-824-7221