Provider Demographics
NPI:1922142447
Name:PROMEDICA CENTRAL PHYSICIANS, LLC
Entity Type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIANS, LLC
Other - Org Name:METAMORA FAMILY PRACTICE
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 1:1990 COUNTY ROAD U
Mailing Address - Street 2:
Mailing Address - City:METAMORA
Mailing Address - State:OH
Mailing Address - Zip Code:43540-9717
Mailing Address - Country:US
Mailing Address - Phone:419-644-4818
Mailing Address - Fax:419-644-2589
Practice Address - Street 1:1990 COUNTY ROAD U
Practice Address - Street 2:
Practice Address - City:METAMORA
Practice Address - State:OH
Practice Address - Zip Code:43540-9717
Practice Address - Country:US
Practice Address - Phone:419-644-4818
Practice Address - Fax:419-644-2589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-17
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4036950012OtherDMERC
OH4036950012OtherDMERC