Provider Demographics
NPI:1871912410
Name:PROMEDICA CENTRAL PHYSICIANS
Entity type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIANS
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 FL 3
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5700 MONROE ST UNIT 211
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2737
Practice Address - Country:US
Practice Address - Phone:419-776-1004
Practice Address - Fax:419-776-1020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-10
Last Update Date:2025-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH156F00000X, 207W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4036950012Medicare NSC