Provider Demographics
NPI:1295879716
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: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 1:650 BEAVER CREEK CIR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1734
Mailing Address - Country:US
Mailing Address - Phone:419-891-6262
Mailing Address - Fax:419-893-1196
Practice Address - Street 1:650 BEAVER CREEK CIR
Practice Address - Street 2:SUITE 130
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1734
Practice Address - Country:US
Practice Address - Phone:419-891-6262
Practice Address - Fax:419-893-1196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPR9302268Medicare ID - Type Unspecified