Provider Demographics
NPI:1790826535
Name:PROMEDICA CENTRAL PHYSICIAN, LLC
Entity Type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIAN, LLC
Other - Org Name:SUNFOREST OB GYN ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:KENYA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-824-7288
Mailing Address - Street 1:3740 W SYLVANIA AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4461
Mailing Address - Country:US
Mailing Address - Phone:419-473-6622
Mailing Address - Fax:419-473-6627
Practice Address - Street 1:3740 W SYLVANIA AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4461
Practice Address - Country:US
Practice Address - Phone:419-473-6622
Practice Address - Fax:419-473-6627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPR9302271Medicare ID - Type Unspecified
OH4036950011Medicare NSC