=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427609312
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROMEDICA CENTRAL CORPORATION OF MICHIGAN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2019
-----------------------------------------------------
Last Update Date | 04/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6869 S OCCIDENTAL RD
-----------------------------------------------------
City | TECUMSEH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49286-9784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-423-4777
-----------------------------------------------------
Fax | 517-423-7257
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 MADISON AVE FL 3
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43604-1516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR, SYSTEM CREDENTIALING
-----------------------------------------------------
Name | TANYA WINES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 567-585-0422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------