Provider Demographics
NPI:1407996333
Name:PROMEDICA CENTRAL PHYSICIANS
Entity Type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIANS
Other - Org Name:TERRY M. GIBBS, D.O.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BAHNSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-824-7334
Mailing Address - Street 1:5308 HARROUN RD
Mailing Address - Street 2:SUITE 175
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2114
Mailing Address - Country:US
Mailing Address - Phone:419-824-5608
Mailing Address - Fax:419-885-3686
Practice Address - Street 1:5308 HARROUN RD
Practice Address - Street 2:SUITE 175
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2114
Practice Address - Country:US
Practice Address - Phone:419-824-5608
Practice Address - Fax:419-885-3686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH40369550006OtherDMERC
OH40369550006OtherDMERC