Basic Information
Provider Information | |||||||||
NPI: | 1962810697 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LIMA MEMORIAL PROFESSIONAL CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LIMA MEMORIAL HEALTH SYSTEM AT KENTON MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1001 BELLEFONTAINE AVE | ||||||||
Address2: |   | ||||||||
City: | LIMA | ||||||||
State: | OH | ||||||||
PostalCode: | 458042800 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4199984575 | ||||||||
FaxNumber: | 4199984586 | ||||||||
Practice Location | |||||||||
Address1: | 1211 E COLUMBUS ST | ||||||||
Address2: |   | ||||||||
City: | KENTON | ||||||||
State: | OH | ||||||||
PostalCode: | 433261760 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4196750668 | ||||||||
FaxNumber: | 4196750669 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/25/2014 | ||||||||
LastUpdateDate: | 04/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | UTZ | ||||||||
AuthorizedOfficialFirstName: | JEFFREY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF LMP | ||||||||
AuthorizedOfficialTelephone: | 4199984668 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1457474900 | 01 | OH | GROUP NPI | OTHER | 2223703 | 05 | OH |   | MEDICAID |