Provider Demographics
NPI:1477990893
Name:PROMEDICA GENITO-URINARY SURGEONS LLC
Entity Type:Organization
Organization Name:PROMEDICA GENITO-URINARY SURGEONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DWYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-824-7334
Mailing Address - Street 1:121 WESTFIELD DR
Mailing Address - Street 2:
Mailing Address - City:ARCHBOLD
Mailing Address - State:OH
Mailing Address - Zip Code:43502-1056
Mailing Address - Country:US
Mailing Address - Phone:537-444-4748
Mailing Address - Fax:567-444-4750
Practice Address - Street 1:121 WESTFIELD DR
Practice Address - Street 2:
Practice Address - City:ARCHBOLD
Practice Address - State:OH
Practice Address - Zip Code:43502-1056
Practice Address - Country:US
Practice Address - Phone:537-444-4748
Practice Address - Fax:567-444-4750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-24
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty