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General NPI Number Information
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NPI Number | 1023865730
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Entity Type | Organization
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Legal Business Name | PROMEDEUS MEDICAL GROUP, LLC
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Dates
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Enumeration Date | 05/01/2024
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Last Update Date | 05/01/2024
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Provider Practice Location Address
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Address Line | 280 S ASHLAND AVE
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City | LEXINGTON
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State | KY
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Zip | 40502-1728
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Country | US
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Telephone | 956-497-4285
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Fax |
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Provider Business Mailing Address
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Address Line | 3150 CUSTER DR STE 101
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City | LEXINGTON
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State | KY
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Zip | 40517-4010
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Country | US
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Telephone | 859-537-8419
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. JESUS TOVAR
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Credential | MD
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Telephone | 956-497-4285
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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