Provider Demographics
NPI:1457632309
Name:PROMEDICA CENTRAL PHYSICIANS
Entity Type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIANS
Other - Org Name:MARK G LOOMUS MD
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 1:1601 BRIGHAM DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-7114
Mailing Address - Country:US
Mailing Address - Phone:419-872-7246
Mailing Address - Fax:419-872-3754
Practice Address - Street 1:1601 BRIGHAM DR
Practice Address - Street 2:SUITE 150
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-7114
Practice Address - Country:US
Practice Address - Phone:419-872-7246
Practice Address - Fax:419-872-3754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty