Provider Demographics
NPI:1194096693
Name:PROMEDICA CENTRAL PHYSICIANS
Entity type:Organization
Organization Name:PROMEDICA CENTRAL PHYSICIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BAHNSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-824-7334
Mailing Address - Street 1:777 KIMOLE LN
Mailing Address - Street 2:SUITE 250
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1478
Mailing Address - Country:US
Mailing Address - Phone:888-593-5815
Mailing Address - Fax:
Practice Address - Street 1:777 KIMOLE LN
Practice Address - Street 2:SUITE 250
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1478
Practice Address - Country:US
Practice Address - Phone:888-593-5815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-16
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty