Provider Demographics
NPI:1689072407
Name:PROMEDICA CENTRAL PHYSICIANS LLC
Entity Type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIANS LLC
Other - Org Name:PROMEDICA PHYSICIANS EYE CARE
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:DWYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-824-7334
Mailing Address - Street 1:435 S HAWLEY ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43609-2344
Mailing Address - Country:US
Mailing Address - Phone:419-242-3937
Mailing Address - Fax:419-776-1020
Practice Address - Street 1:435 S HAWLEY ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43609-2344
Practice Address - Country:US
Practice Address - Phone:419-242-3937
Practice Address - Fax:419-776-1020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH152W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty