Basic Information
| Provider Information | |||||||||
| NPI: | 1164566287 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROMEDICA CENTRAL PHYSICIANS, LLC | ||||||||
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| OtherOrganizationName: | TODD RUSSELL, M.D. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2109 HUGHES DR | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192912003 | ||||||||
| FaxNumber: | 4194796977 | ||||||||
| Practice Location | |||||||||
| Address1: | 2109 HUGHES DR | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192912003 | ||||||||
| FaxNumber: | 4194796977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DIXON | ||||||||
| AuthorizedOfficialFirstName: | KENYA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 4198247288 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.