Basic Information
| Provider Information | |||||||||
| NPI: | 1083959522 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROMEDICA CENTRAL PHYSICIANS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROMEDICA CHILDREN'S SPECIALTIES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 730 N MACOMB ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481622900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192917010 | ||||||||
| FaxNumber: | 4194796917 | ||||||||
| Practice Location | |||||||||
| Address1: | 730 N MACOMB ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481622900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192917010 | ||||||||
| FaxNumber: | 4194796917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2012 | ||||||||
| LastUpdateDate: | 02/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | KNUEVEN | ||||||||
| AuthorizedOfficialFirstName: | KRISTIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 5675851969 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
No ID Information.