Provider Demographics
NPI:1679844955
Name:PROMEDICA CENTRAL PHYSICIANS
Entity Type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIANS
Other - Org Name:PATRICK WHITE MD AND JOSE PARODI MD
Other - Org Type:Doing Business As
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 1:725 S SHOOP AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-1702
Mailing Address - Country:US
Mailing Address - Phone:419-330-2740
Mailing Address - Fax:
Practice Address - Street 1:725 S SHOOP AVE
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1702
Practice Address - Country:US
Practice Address - Phone:419-330-2740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty