1508023896 NPI number — LIMA MEMORIAL PROFESSIONAL CORPORATION

Table of content: (NPI 1508023896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508023896 NPI number — LIMA MEMORIAL PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIMA MEMORIAL PROFESSIONAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LIMA MEMORIAL DIABETIC CENTER AT MEDPARK
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508023896
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 BELLEFONTAINE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIMA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45804-2800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-998-4575
Provider Business Mailing Address Fax Number:
419-998-4586

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 N EASTOWN RD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIMA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45807-2268
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-998-8291
Provider Business Practice Location Address Fax Number:
419-998-8292
Provider Enumeration Date:
05/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
UTZ
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR IF LMP
Authorized Official Telephone Number:
419-998-4668

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1457474900 . This is a "GROUP NPI" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2223703 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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