Provider Demographics
NPI:1023865730
Name:PROMEDEUS MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:PROMEDEUS MEDICAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:
Authorized Official - Last Name:TOVAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-497-4285
Mailing Address - Street 1:3150 CUSTER DR STE 101
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-4010
Mailing Address - Country:US
Mailing Address - Phone:859-537-8419
Mailing Address - Fax:
Practice Address - Street 1:280 S ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40502-1728
Practice Address - Country:US
Practice Address - Phone:956-497-4285
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty