Provider Demographics
NPI:1366795221
Name:PROMEDICA GENITO-URINARY SURGEONS LLC
Entity type:Organization
Organization Name:PROMEDICA GENITO-URINARY SURGEONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position: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 1:100 MADISON AVE
Mailing Address - Street 2:MSC-S38805
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604
Mailing Address - Country:US
Mailing Address - Phone:844-373-0871
Mailing Address - Fax:419-885-3921
Practice Address - Street 1:2120 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3834
Practice Address - Country:US
Practice Address - Phone:419-531-8558
Practice Address - Fax:419-531-8798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207L00000X, 363A00000X, 363L00000X, 367500000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0076667Medicaid
OHH163570Medicare PIN