Basic Information
| Provider Information | |||||||||
| NPI: | 1487781233 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROMEDICA NORTHWEST OHIO CARDIOLOGY CONSULTANTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 VAN BUREN ST | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | FOSTORIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448301534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194357734 | ||||||||
| FaxNumber: | 4194366623 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 VAN BUREN ST | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | FOSTORIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448301534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194357734 | ||||||||
| FaxNumber: | 4194366623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 08/12/2011 | ||||||||
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| AuthorizedOfficialLastName: | BAHNSEN | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 4198247334 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 341898679 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 341898679-003 | 01 | OH | TRICARE | OTHER | 341898679-03 | 01 | OH | BWC | OTHER | CJ9183 | 01 | OH | RRMC | OTHER |