Provider Demographics
NPI:1609172493
Name:PROMEDICA CENTRAL PHYSICIANS, LLC
Entity Type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIANS, LLC
Other - Org Name:PEDIATRIC HOSPITALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KENYA
Authorized Official - Middle Name:I
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-824-7288
Mailing Address - Street 1:PO BOX 2804
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-0804
Mailing Address - Country:US
Mailing Address - Phone:419-291-4000
Mailing Address - Fax:419-479-6102
Practice Address - Street 1:2142 N COVE BLVD
Practice Address - Street 2:5-NORTH PEDS
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3895
Practice Address - Country:US
Practice Address - Phone:419-291-4000
Practice Address - Fax:419-479-6102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-27
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty