Provider Demographics
NPI:1346587276
Name:PROMEDICA CENTRAL PHYSICIAN, LLC
Entity Type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIAN, LLC
Other - Org Name:PROMEDICA PHYSICIANS ADULT MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING CORRDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCUNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-824-7264
Mailing Address - Street 1:2150 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3834
Mailing Address - Country:US
Mailing Address - Phone:419-291-3300
Mailing Address - Fax:419-479-3298
Practice Address - Street 1:2150 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3834
Practice Address - Country:US
Practice Address - Phone:419-291-3300
Practice Address - Fax:419-479-3298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty