Provider Demographics
NPI:1699056549
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 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 1:5300 HARROUN RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2182
Mailing Address - Country:US
Mailing Address - Phone:419-824-6350
Mailing Address - Fax:419-885-3847
Practice Address - Street 1:5300 HARROUN RD
Practice Address - Street 2:SUITE 202
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2182
Practice Address - Country:US
Practice Address - Phone:419-824-6350
Practice Address - Fax:419-885-3847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty