Basic Information
Provider Information | |||||||||
NPI: | 1184619801 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROMEDICA CONTINUING CARE SERVICES CORP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PROMEDICA HOME MEDICAL EQUIPMENT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1801 RICHARDS RD | ||||||||
Address2: |   | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436071037 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4194693780 | ||||||||
FaxNumber: | 4194693781 | ||||||||
Practice Location | |||||||||
Address1: | 601 PARKWAY DR | ||||||||
Address2: |   | ||||||||
City: | FOSTORIA | ||||||||
State: | OH | ||||||||
PostalCode: | 448301592 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4194360004 | ||||||||
FaxNumber: | 4194368190 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/19/2005 | ||||||||
LastUpdateDate: | 02/10/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROBERTS | ||||||||
AuthorizedOfficialFirstName: | GLADEEN | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4194693780 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
ID Information
ID | Type | State | Issuer | Description | 000000155945 | 01 | OH | ANTHEM | OTHER | 707795 | 01 | OH | BUCKEYE COMMUNITY | OTHER | 81337 | 01 | OH | NPN | OTHER | 10133 | 01 | OH | PARAMOUNT HEALTH CARE | OTHER | 2828668 | 05 | OH |   | MEDICAID | 4405016 | 05 | MI |   | MEDICAID |