Provider Demographics
NPI:1871912410
Name:PROMEDICA CENTRAL PHYSICIANS LLC
Entity type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIANS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:R
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:567-585-1997
Mailing Address - Street 1:1 SEAGATE
Mailing Address - Street 2:SUITE 800
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1558
Mailing Address - Country:US
Mailing Address - Phone:567-585-1997
Mailing Address - Fax:419-824-7359
Practice Address - Street 1:5700 MONROE ST
Practice Address - Street 2:SUITE 211
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2767
Practice Address - Country:US
Practice Address - Phone:419-776-1004
Practice Address - Fax:419-776-1020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-10
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH152W00000X, 156F00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4036950012Medicare NSC