=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568733848
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROMEDICA CENTRAL PHYSICIANS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2012
-----------------------------------------------------
Last Update Date | 01/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2901 N REYNOLDS RD
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43615-2035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-578-7700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2901 N REYNOLDS RD
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43615-2035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-578-7700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SUPERVISOR
-----------------------------------------------------
Name | AMY L BAHNSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-824-7334
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------