Basic Information
| Provider Information | |||||||||
| NPI: | 1194049866 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXECUTIVE UROLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 HAYES AVE | ||||||||
| Address2: | BLDG D | ||||||||
| City: | SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448707248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196278771 | ||||||||
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| Practice Location | |||||||||
| Address1: | 278 BENEDICT AVE | ||||||||
| Address2: | SUITE 650 | ||||||||
| City: | NORWALK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448572399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196684328 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2010 | ||||||||
| LastUpdateDate: | 03/24/2010 | ||||||||
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| AuthorizedOfficialLastName: | RICE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4196278771 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 2281972 | 05 | OH | MEDICAID | CG9157 | 01 | OH | RAILROAD MEDICARE | OTHER |