Provider Demographics
NPI:1659676708
Name:PROMEDICA MONROE CARDIOLOGY, PLLC
Entity Type:Organization
Organization Name:PROMEDICA MONROE CARDIOLOGY, PLLC
Other - Org Name:PROMEDICA CARDIOLOGY OF MONROE
Other - Org Type:Doing Business As
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 1:730 N MACOMB ST
Practice Address - Street 2:SUITE 429
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-2900
Practice Address - Country:US
Practice Address - Phone:734-242-7060
Practice Address - Fax:734-241-7580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-21
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3126683Medicaid
OH3126683Medicaid
OH9393231Medicare PIN