Basic Information
| Provider Information | |||||||||
| NPI: | 1528279940 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIMA UROLOGY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 770 WEST HIGH STREET | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458015901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192288950 | ||||||||
| FaxNumber: | 4192247904 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 STATE ROUTE 224 | ||||||||
| Address2: | |||||||||
| City: | GLANDORF | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192288950 | ||||||||
| FaxNumber: | 4192247904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2007 | ||||||||
| LastUpdateDate: | 04/01/2008 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4192288950 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 2206759 | 05 | OH | MEDICAID |