Basic Information
| Provider Information | |||||||||
| NPI: | 1053455170 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROMEDICA CENTRAL PHYSICIANS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PERRYSBURG PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 BRIGHAM DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435517114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198727700 | ||||||||
| FaxNumber: | 4198740196 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 BRIGHAM DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435517114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198727700 | ||||||||
| FaxNumber: | 4198740196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | GOVAN | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4198247221 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 5835390 | 01 | OH | AETNA | OTHER | 0999273 | 05 | OH | MEDICAID |