Provider Demographics
NPI:1639458383
Name:PROMEDICA NORTHWEST OHIO CARDIOLOGY CONSULTANTS, LLC
Entity Type:Organization
Organization Name:PROMEDICA NORTHWEST OHIO CARDIOLOGY CONSULTANTS, LLC
Other - Org Name:
Other - Org Type:
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 1:615 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-2001
Mailing Address - Country:US
Mailing Address - Phone:419-734-3131
Mailing Address - Fax:419-732-8217
Practice Address - Street 1:615 FULTON ST
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-2001
Practice Address - Country:US
Practice Address - Phone:419-734-3131
Practice Address - Fax:419-732-8217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty