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General NPI Number Information
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NPI Number | 1114112273
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Entity Type | Organization
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Legal Business Name | PROMEDICA CENTRAL PHYSICIANS, LLC
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Dates
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Enumeration Date | 09/12/2007
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Last Update Date | 02/18/2008
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Provider Practice Location Address
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Address Line | 1200 RALSTON AVE
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City | DEFIANCE
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State | OH
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Zip | 43512-1396
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Country | US
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Telephone | 419-783-6847
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Fax | 419-782-7580
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Provider Business Mailing Address
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Address Line | 1200 RALSTON AVE
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City | DEFIANCE
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State | OH
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Zip | 43512-1396
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Country | US
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Telephone | 419-783-6847
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Fax | 419-782-7580
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Authorized Official
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Title or Position | CREDENTIALING SUPERVISOR
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Name | KIMBERLY GOVAN
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Credential |
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Telephone | 419-824-7221
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 35.078360
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License Number State | OH
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