Provider Demographics
NPI:1568733848
Name:PROMEDICA CENTRAL PHYSICIANS
Entity Type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIANS
Other - Org Name:PROMEDICA WILDWOOD ORTHOPAEDIC AND SPINE HOSPITALISTS
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 1:2901 N REYNOLDS RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-2035
Mailing Address - Country:US
Mailing Address - Phone:419-578-7700
Mailing Address - Fax:
Practice Address - Street 1:2901 N REYNOLDS RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-2035
Practice Address - Country:US
Practice Address - Phone:419-578-7700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty