Provider Demographics
NPI:1063691269
Name:PROMEDICA CENTRAL PHYSCIANS, LLC
Entity type:Organization
Organization Name:PROMEDICA CENTRAL PHYSCIANS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KNUEVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:567-585-1969
Mailing Address - Street 1:3140 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-2920
Mailing Address - Country:US
Mailing Address - Phone:419-537-5111
Mailing Address - Fax:419-537-5131
Practice Address - Street 1:3140 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-2920
Practice Address - Country:US
Practice Address - Phone:419-537-5111
Practice Address - Fax:419-537-5131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric EndocrinologyGroup - Single Specialty