Provider Demographics
NPI:1568001352
Name:PROMEDICA CENTRAL PHYSICIANS
Entity Type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIANS
Other - Org Name:STELLANTIS/JEEP ONSITE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:WINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:567-585-0422
Mailing Address - Street 1:333 N SUMMIT ST FL 7
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3500 EXECUTIVE PKWY
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1319
Practice Address - Country:US
Practice Address - Phone:567-585-5337
Practice Address - Fax:567-585-5336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-27
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center