Basic Information
| Provider Information | |||||||||
| NPI: | 1861958076 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROMEDICA CENTRAL CORPORATION OF MICHIGAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 SEAGATE STE 800 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436041558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5675851969 | ||||||||
| FaxNumber: | 4198247359 | ||||||||
| Practice Location | |||||||||
| Address1: | 324 E MAUMEE ST | ||||||||
| Address2: | |||||||||
| City: | ADRIAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492212961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172653307 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2019 | ||||||||
| LastUpdateDate: | 02/12/2019 | ||||||||
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| AuthorizedOfficialLastName: | KNUEVEN | ||||||||
| AuthorizedOfficialFirstName: | KRISTIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 5675851969 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROMEDICA PHYSICIAN GROUP INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.