Healthcare Provider Details

I. General information

NPI: 1548461288
Provider Name (Legal Business Name): PROMEDICA CENTRAL PHYSICIANS,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 02/05/2021
Certification Date: 02/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 HUGHES DR SUITE 640
TOLEDO OH
43606-3845
US

IV. Provider business mailing address

2121 HUGHES DR SUITE 640
TOLEDO OH
43606-3845
US

V. Phone/Fax

Practice location:
  • Phone: 419-291-2207
  • Fax: 419-479-6998
Mailing address:
  • Phone: 419-291-2207
  • Fax: 419-479-6998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number
License Number State

VIII. Authorized Official

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