Basic Information
| Provider Information | |||||||||
| NPI: | 1255537403 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROVIDENCE UROLOGY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1428 ELLEN ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MONROE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281125285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042894361 | ||||||||
| FaxNumber: | 7042834705 | ||||||||
| Practice Location | |||||||||
| Address1: | 1428 ELLEN ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MONROE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281125285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042894361 | ||||||||
| FaxNumber: | 7042834705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | LIM | ||||||||
| AuthorizedOfficialFirstName: | ARTHUR | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/CO-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7042894361 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | NC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 208800000X | 200101464 | NC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 208800000X | 200000981 | NC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.