Basic Information
| Provider Information | |||||||||
| NPI: | 1306105150 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROMEDICA MULTI SPECIALTY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N SUMMIT ST FL 7 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436041531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5675851964 | ||||||||
| FaxNumber: | 4198247359 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 N SUMMIT ST FL 7 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436041531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5675851964 | ||||||||
| FaxNumber: | 4198247359 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2012 | ||||||||
| LastUpdateDate: | 02/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | MCCUNE | ||||||||
| AuthorizedOfficialFirstName: | LORRAINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 5675851964 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 207QS0010X | OH | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0065185 | 05 | OH | MEDICAID |