Provider Demographics
NPI:1306105150
Name:PROMEDICA MULTI SPECIALTY PHYSICIANS
Entity type:Organization
Organization Name:PROMEDICA MULTI SPECIALTY PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCUNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:567-585-1964
Mailing Address - Street 1:100 MADISON AVE
Mailing Address - Street 2:MSC-S38805
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1531
Mailing Address - Country:US
Mailing Address - Phone:567-585-1964
Mailing Address - Fax:419-824-7359
Practice Address - Street 1:100 MADISON AVE
Practice Address - Street 2:MSC-S38805
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-1531
Practice Address - Country:US
Practice Address - Phone:567-585-1964
Practice Address - Fax:419-824-7359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207QS0010X, 2086S0122X, 207Q00000X
207RE0101X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0065185Medicaid