Provider Demographics
NPI:1588624696
Name:PROMEDICA CENTRAL CORPORATION OF MICHIGAN
Entity Type:Organization
Organization Name:PROMEDICA CENTRAL CORPORATION OF MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, SYSTEM 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 1:100 MADISON AVE
Mailing Address - Street 2:MSC-S38805
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604
Mailing Address - Country:US
Mailing Address - Phone:844-373-0871
Mailing Address - Fax:419-885-3921
Practice Address - Street 1:100 MADISON AVE
Practice Address - Street 2:MSC-S38805
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604
Practice Address - Country:US
Practice Address - Phone:844-373-0871
Practice Address - Fax:419-885-3921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207L00000X, 207R00000X, 207V00000X, 208000000X, 261QR1300X
MI207Q00000X, 207RC0000X, 207RE0101X, 207X00000X, 207Y00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI160D610660OtherBCBSMI
MI500E811000OtherBCBSMI
MI040D610940OtherBCBSMI
MI080E810210OtherBCBSMI
MICD9268OtherRRMC
OH2002924Medicaid
OH2002924Medicaid