Provider Demographics
NPI:1447394564
Name:PROMEDICA CENTRAL PHYSICIAN, LLC
Entity Type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIAN, LLC
Other - Org Name:SYLVANIA INTERNAL MEDICINE
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 1:4129 N HOLLAND SYLVANIA RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4809
Mailing Address - Country:US
Mailing Address - Phone:419-885-4231
Mailing Address - Fax:419-885-5314
Practice Address - Street 1:4129 N HOLLAND SYLVANIA RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4809
Practice Address - Country:US
Practice Address - Phone:419-885-4231
Practice Address - Fax:419-885-5314
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
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPR9302284Medicare ID - Type Unspecified