Basic Information
| Provider Information | |||||||||
| NPI: | 1033388558 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDISON LAKES UROLOGY PLYMOUTH OFFICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 S NAPPANEE ST | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465142066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742963200 | ||||||||
| FaxNumber: | 5742963300 | ||||||||
| Practice Location | |||||||||
| Address1: | 1919 LAKE AVE | ||||||||
| Address2: | SUITE 109 | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465637830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5749352138 | ||||||||
| FaxNumber: | 5749352136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2008 | ||||||||
| LastUpdateDate: | 05/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | BUSBY | ||||||||
| AuthorizedOfficialFirstName: | DARRYL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5742963200 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ELKHART CLINIC LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.