NPIMap

Organization Active NPI

Promedica Genito-Urinary Surgeons LLC

  • Urology Physician
  • Toledo, OH
National Provider Identifier
1366795221
Registry record updated Oct 12, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Urology PhysicianTaxonomy code 208800000X
Legal business name
PROMEDICA GENITO-URINARY SURGEONS LLC
Practice address
2120 W Central Ave
Toledo, OH 43606-3834
Phone
(419) 531-8558
Fax
(419) 531-8798
NPI assigned
Oct 17, 2012
Last updated
Oct 12, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 12, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kristin Knueven
Title
Supervisor
Phone
(567) 585-1969

Specialties & licenses 5

Specialty (taxonomy)CodeLicenseStatePrimary
Anesthesiology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207L00000X OH
Urology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208800000X OH Primary
Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363A00000X OH
Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363L00000X OH
Certified Registered Nurse AnesthetistGroup: 193200000X MULTI-SPECIALTY GROUP 367500000X OH

Addresses

Primary practice location

2120 W Central Ave
Toledo, OH 43606-3834

Mailing address

100 Madison Ave
MSC-S38805
Toledo, OH 43604
Phone (844) 373-0871

Other identifiers 1

IdentifierTypeStateIssuer
0076667MedicaidOH

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OH, MI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20130214000211 OH Part B Supplier - Clinic/Group Practice 3971757238 Receives reassigned benefits from 23 practitioners
Practice locations: Defiance, OH; Toledo, OH; Maumee, OH; Fremont, OH; Fostoria, OH; Archbold, OH
O20130926000835 MI Part B Supplier - Clinic/Group Practice 3971757238 Receives reassigned benefits from 11 practitioners
Practice locations: Monroe, MI

National Provider Directory

National Provider Directory

Locations

214 E Elm Ave
Ste 101
Monroe, MI 48162
Phone (734) 243-9620

905 N Macomb St
Ste 5
Monroe, MI 48162
Phone (734) 243-9620

1250 Ralston Ave
Ste 203
Defiance, OH 43512
Phone (419) 783-6915

605 3rd Ave
Ste A
Fremont, OH 43420
Phone (419) 332-7221

605 3rd Ave
Ste B
Fremont, OH 43420
Phone (419) 334-3879

5180 Chappel Dr
Ste 4B5B
Perrysburg, OH 43551

5180 Chappel Dr
Ste B4
Perrysburg, OH 43551

1 Seagate
Ste 800
Toledo, OH 43604

Practitioners & affiliated clinicians

Practitioners 29

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 29

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1350432000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1697068800000",
    "number": "1366795221",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 MADISON AVE",
            "address_2": "MSC-S38805",
            "city": "TOLEDO",
            "state": "OH",
            "postal_code": "43604",
            "telephone_number": "844-373-0871",
            "fax_number": "419-885-3921"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2120 W CENTRAL AVE",
            "city": "TOLEDO",
            "state": "OH",
            "postal_code": "436063834",
            "telephone_number": "419-531-8558",
            "fax_number": "419-531-8798"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROMEDICA GENITO-URINARY SURGEONS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-10-17",
        "last_updated": "2023-10-12",
        "certification_date": "2023-10-12",
        "status": "A",
        "authorized_official_last_name": "KNUEVEN",
        "authorized_official_first_name": "KRISTIN",
        "authorized_official_title_or_position": "SUPERVISOR",
        "authorized_official_telephone_number": "567-585-1969"
    },
    "taxonomies": [
        {
            "code": "207L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Anesthesiology",
            "state": "OH",
            "license": null,
            "primary": false
        },
        {
            "code": "208800000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Urology",
            "state": "OH",
            "license": null,
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": "OH",
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": "OH",
            "license": null,
            "primary": false
        },
        {
            "code": "367500000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Anesthetist, Certified Registered",
            "state": "OH",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0076667",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Toledo, OH

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 12, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.