Basic Information
| Provider Information | |||||||||
| NPI: | 1285844670 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UROLOGY SPECIALISTS OF NORTHWEST OHIO, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7640 SYLVANIA AVE | ||||||||
| Address2: | SUITE L | ||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435609729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195171022 | ||||||||
| FaxNumber: | 4195171026 | ||||||||
| Practice Location | |||||||||
| Address1: | 7640 W SYLVANIA AVE STE L | ||||||||
| Address2: | SUITE L | ||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435609263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195171022 | ||||||||
| FaxNumber: | 4195171026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 11/05/2007 | ||||||||
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| AuthorizedOfficialLastName: | HOPPS | ||||||||
| AuthorizedOfficialFirstName: | CARIN | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4195171022 | ||||||||
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| 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 | 35082931 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 2419172 | 05 | OH | MEDICAID |