Basic Information
Provider Information | |||||||||
NPI: | 1356485478 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PROMEDICA CENTRAL PHYSICIANS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SOUTH TOLEDO PEDIATRIC ASSOCISTES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 660 BEAVER CREEK CIR | ||||||||
Address2: | SUITE 100 | ||||||||
City: | MAUMEE | ||||||||
State: | OH | ||||||||
PostalCode: | 435371745 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4198916221 | ||||||||
FaxNumber: | 4198933394 | ||||||||
Practice Location | |||||||||
Address1: | 660 BEAVER CREEK CIR | ||||||||
Address2: | SUITE 100 | ||||||||
City: | MAUMEE | ||||||||
State: | OH | ||||||||
PostalCode: | 435371745 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4198916221 | ||||||||
FaxNumber: | 4198933394 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/20/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DIXON | ||||||||
AuthorizedOfficialFirstName: | KENYA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING ASSISTANT | ||||||||
AuthorizedOfficialTelephone: | 4198247288 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.