Provider Demographics
NPI:1578604872
Name:PROMEDICA CENTRAL PHYSICIANS,LLC
Entity Type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIANS,LLC
Other - Org Name:OAK VALLEY PRIMARY CARE PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-824-7221
Mailing Address - Street 1:22 TURTLE CREEK CIR
Mailing Address - Street 2:SUITE E
Mailing Address - City:SWANTON
Mailing Address - State:OH
Mailing Address - Zip Code:43558-8591
Mailing Address - Country:US
Mailing Address - Phone:419-825-2387
Mailing Address - Fax:419-825-3783
Practice Address - Street 1:22 TURTLE CREEK CIR
Practice Address - Street 2:SUITE E
Practice Address - City:SWANTON
Practice Address - State:OH
Practice Address - Zip Code:43558-8591
Practice Address - Country:US
Practice Address - Phone:419-825-2387
Practice Address - Fax:419-825-3783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4036950014Medicare NSC