Provider Demographics
NPI:1174667299
Name:PROMEDICA CENTRSL PHYSICIANS, LLC
Entity Type:Organization
Organization Name:PROMEDICA CENTRSL PHYSICIANS, LLC
Other - Org Name:WEST CENTRAL MEDICAL GROUP
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 1:3909 WOODLEY RD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-1169
Mailing Address - Country:US
Mailing Address - Phone:419-291-6760
Mailing Address - Fax:419-472-4359
Practice Address - Street 1:3909 WOODLEY RD
Practice Address - Street 2:SUITE 600
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1169
Practice Address - Country:US
Practice Address - Phone:419-291-6760
Practice Address - Fax:419-472-4359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4036950008OtherDMERC
OHPR9302277Medicare ID - Type Unspecified