Provider Demographics
NPI:1841485802
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 SUPERVISOR
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 1:501 VAN BUREN ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:FOSTORIA
Mailing Address - State:OH
Mailing Address - Zip Code:44830-1534
Mailing Address - Country:US
Mailing Address - Phone:419-435-5454
Mailing Address - Fax:419-436-6623
Practice Address - Street 1:501 VAN BUREN ST
Practice Address - Street 2:SUITE 206
Practice Address - City:FOSTORIA
Practice Address - State:OH
Practice Address - Zip Code:44830-1534
Practice Address - Country:US
Practice Address - Phone:419-435-5454
Practice Address - Fax:419-436-6623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4036950019Medicare NSC