Basic Information
Provider Information | |||||||||
NPI: | 1588694814 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EXECUTIVE UROLOGY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2800 HAYES AVENUE | ||||||||
Address2: | BLDG D | ||||||||
City: | SANDUSKY | ||||||||
State: | OH | ||||||||
PostalCode: | 44870 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4196278771 | ||||||||
FaxNumber: | 4196270363 | ||||||||
Practice Location | |||||||||
Address1: | 2800 HAYES AVE | ||||||||
Address2: | BLDG D | ||||||||
City: | SANDUSKY | ||||||||
State: | OH | ||||||||
PostalCode: | 448707248 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4196278771 | ||||||||
FaxNumber: | 4196270363 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2006 | ||||||||
LastUpdateDate: | 11/21/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RICE | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | W | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4196278771 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MC | ||||||||
NPICertificationDate: |   |
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 | 2274793 | 05 | OH |   | MEDICAID | 2281972 | 05 | OH |   | MEDICAID | CG9157 | 01 | OH | RAILROAD MEDICARE | OTHER | 2282328 | 05 | OH |   | MEDICAID |