Provider Demographics
NPI:1073657193
Name:PROMEDICA CENTRAL PHYSICIANS, LLC
Entity Type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIANS, LLC
Other - Org Name:CHILDREN'S SURGICAL SERVICES OF NORTHWEST OHIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:KENYA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-824-7288
Mailing Address - Street 1:2121 HUGHES DR
Mailing Address - Street 2:SUITE 620
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3845
Mailing Address - Country:US
Mailing Address - Phone:419-291-2126
Mailing Address - Fax:419-291-6967
Practice Address - Street 1:2121 HUGHES DR
Practice Address - Street 2:SUITE 620
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3845
Practice Address - Country:US
Practice Address - Phone:419-291-2126
Practice Address - Fax:419-291-6967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPR9336181Medicare ID - Type Unspecified