Provider Demographics
NPI:1518202050
Name:PROMEDICA CENTRAL PHYSICIANS LLC
Entity Type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIANS LLC
Other - Org Name:PROMEDICA CHILDREN'S SPECIALTIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KNUEVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:567-585-1969
Mailing Address - Street 1:1912 HAYES AVE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-4736
Mailing Address - Country:US
Mailing Address - Phone:419-557-6767
Mailing Address - Fax:419-557-6783
Practice Address - Street 1:1912 HAYES AVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-4736
Practice Address - Country:US
Practice Address - Phone:419-557-6767
Practice Address - Fax:419-557-6783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-11
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2080P0203X, 2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Multi-Specialty
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Multi-Specialty