Basic Information
| Provider Information | |||||||||
| NPI: | 1285616722 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | URSE | ||||||||
| FirstName: | GERALDINE | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | URSE | ||||||||
| OtherFirstName: | GERALDINE | ||||||||
| OtherMiddleName: | NOBLE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2030 STRINGTOWN RD | ||||||||
| Address2: | |||||||||
| City: | GROVE CITY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431233993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145440101 | ||||||||
| FaxNumber: | 6145440102 | ||||||||
| Practice Location | |||||||||
| Address1: | 2030 STRINGTOWN RD | ||||||||
| Address2: | |||||||||
| City: | GROVE CITY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431233993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145440101 | ||||||||
| FaxNumber: | 6145440102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 12/20/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OH005976 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0236588 | 05 | OH | MEDICAID |