Basic Information
| Provider Information | |||||||||
| NPI: | 1285172163 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROMEDICA HEALTH SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 157 N STATE ROUTE 510 | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434209224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192171614 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5308 HARROUN RD STE 280 | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435602190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198241785 | ||||||||
| FaxNumber: | 4198245953 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2017 | ||||||||
| LastUpdateDate: | 02/10/2017 | ||||||||
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| AuthorizedOfficialLastName: | MOYER | ||||||||
| AuthorizedOfficialFirstName: | COURTNEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 4198241785 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PA-C, RD, LD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 50.004996RX | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.