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General NPI Number Information
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NPI Number | 1588091599
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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 | 10/04/2013
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Last Update Date | 10/04/2013
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Provider Practice Location Address
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Address Line | 2751 BAY PARK DR SUITE 202
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City | OREGON
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State | OH
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Zip | 43616-4921
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Country | US
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Telephone | 419-690-7550
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Fax | 419-697-7919
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Provider Business Mailing Address
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Address Line | 2751 BAY PARK DR SUITE 202
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City | OREGON
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State | OH
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Zip | 43616-4921
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Country | US
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Telephone | 419-690-7550
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Fax | 419-697-7919
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Authorized Official
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Title or Position | CREDENTIALING SUPERVISOR
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Name | AMY L DYWER
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Credential |
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Telephone | 419-824-7334
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208C00000X
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Taxonomy Name | Colon & Rectal Surgery Physician
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License Number |
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State | OH
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