Basic Information
Provider Information | |||||||||
NPI: | 1285826156 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROMEDICA CENTRAL PHYSICIANS,LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1601 BRIGHAM DR | ||||||||
Address2: | SUITE 250A | ||||||||
City: | PERRYSBURG | ||||||||
State: | OH | ||||||||
PostalCode: | 435517114 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4198727760 | ||||||||
FaxNumber: | 4198748657 | ||||||||
Practice Location | |||||||||
Address1: | 1601 BRIGHAM DR | ||||||||
Address2: | SUITE 250A | ||||||||
City: | PERRYSBURG | ||||||||
State: | OH | ||||||||
PostalCode: | 435517114 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4198727760 | ||||||||
FaxNumber: | 4198748657 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/15/2007 | ||||||||
LastUpdateDate: | 08/15/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GOVAN | ||||||||
AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 4198247221 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 34007277 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | PEMDING | 05 | OH |   | MEDICAID | PENDING | 01 | OH | AETNA | OTHER | PENDING | 01 | OH | TRICARE | OTHER | PENDING | 01 | OH | MMOH | OTHER |