Provider Demographics
NPI:1053455170
Name:PROMEDICA CENTRAL PHYSICIANS, LLC
Entity Type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIANS, LLC
Other - Org Name:PERRYSBURG PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-824-7221
Mailing Address - Street 1:1601 BRIGHAM DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-7114
Mailing Address - Country:US
Mailing Address - Phone:419-872-7700
Mailing Address - Fax:419-874-0196
Practice Address - Street 1:1601 BRIGHAM DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-7114
Practice Address - Country:US
Practice Address - Phone:419-872-7700
Practice Address - Fax:419-874-0196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5835390OtherAETNA
OH0999273Medicaid
OH5835390OtherAETNA