Provider Demographics
NPI:1811189780
Name:PROMEDICA CENTRAL PHYSICIANS, LLC
Entity Type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIANS, LLC
Other - Org Name:TOLEDO PEDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-824-7221
Mailing Address - Street 1:7140 PORT SYLVANIA DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-1176
Mailing Address - Country:US
Mailing Address - Phone:419-843-8170
Mailing Address - Fax:419-843-1804
Practice Address - Street 1:7140 PORT SYLVANIA DR
Practice Address - Street 2:SUITE 150
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-1176
Practice Address - Country:US
Practice Address - Phone:419-843-8170
Practice Address - Fax:419-843-1804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGMedicare PIN