Basic Information
| Provider Information | |||||||||
| NPI: | 1467447177 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROMEDICA CONTINUING CARE SERVICES CORP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PROMEDICA HOME MEDICAL EQUIPMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 RICHARDS RD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436071037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194693780 | ||||||||
| FaxNumber: | 4194693781 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 RALSTON AVE | ||||||||
| Address2: | |||||||||
| City: | DEFIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435121396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197836973 | ||||||||
| FaxNumber: | 4197834430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2005 | ||||||||
| LastUpdateDate: | 02/10/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBERTS | ||||||||
| AuthorizedOfficialFirstName: | GLADEEN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4194693780 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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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 | 139856 | 01 | MI | CARE CHOICES | OTHER | 4405016 | 01 | MI | MI MEDICAID | OTHER | 707795 | 01 | OH | BUCKEYE COMMUNITY | OTHER | 0259250 | 05 | OH | MEDICAID | 139856 | 01 | MI | TRINITY HEALTH PLANS | OTHER | 10133 | 01 | OH | PARAMOUNT HEALTH CARE | OTHER | 81337 | 01 | OH | NPN | OTHER | 000000155945 | 01 | OH | ANTHEM | OTHER |