Provider Demographics
NPI:1245444959
Name:PROMEDICA CENTRAL PHYSICIANS, LLC
Entity type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIANS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:WINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:567-585-0422
Mailing Address - Street 1:100 MADISON AVE
Mailing Address - Street 2:MSC-S38805
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1531
Mailing Address - Country:US
Mailing Address - Phone:567-585-1969
Mailing Address - Fax:198-247-3594
Practice Address - Street 1:100 MADISON AVE
Practice Address - Street 2:MSC-S38805
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-1531
Practice Address - Country:US
Practice Address - Phone:567-585-1969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2080P0202X, 2080P0203X, 2080P0205X, 2080P0206X, 207X00000X, 2080P0006X, 2080P0207X, 2086S0120X
OH208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric CardiologyGroup - Multi-Specialty
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Multi-Specialty
No2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric EndocrinologyGroup - Multi-Specialty
No2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric GastroenterologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-OncologyGroup - Multi-Specialty
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2763620Medicaid
OH9371731Medicare PIN