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General NPI Number Information
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NPI Number | 1285172163
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Entity Type | Organization
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Legal Business Name | PROMEDICA HEALTH SYSTEM
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Dates
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Enumeration Date | 02/10/2017
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Last Update Date | 02/10/2017
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Provider Practice Location Address
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Address Line | 5308 HARROUN RD STE 280
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City | SYLVANIA
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State | OH
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Zip | 43560-2190
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Country | US
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Telephone | 419-824-1785
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Fax | 419-824-5953
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Provider Business Mailing Address
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Address Line | 157 N STATE ROUTE 510
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City | FREMONT
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State | OH
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Zip | 43420-9224
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Country | US
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Telephone | 419-217-1614
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN ASSISTANT
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Name | COURTNEY MOYER
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Credential | PA-C, RD, LD
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Telephone | 419-824-1785
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 50.004996RX
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License Number State | OH
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