Provider Demographics
NPI:1285826156
Name:PROMEDICA CENTRAL PHYSICIANS,LLC
Entity Type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIANS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
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 250A
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-7114
Mailing Address - Country:US
Mailing Address - Phone:419-872-7760
Mailing Address - Fax:419-874-8657
Practice Address - Street 1:1601 BRIGHAM DR
Practice Address - Street 2:SUITE 250A
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-7114
Practice Address - Country:US
Practice Address - Phone:419-872-7760
Practice Address - Fax:419-874-8657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007277207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPEMDINGMedicaid
OHPENDINGOtherAETNA
OHPENDINGOtherTRICARE
OHPENDINGOtherMMOH
OHPENDINGOtherAETNA