1649329368 NPI number — METRO GOLDEN MEDICAL, LLC

Table of content: (NPI 1649329368)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649329368 NPI number — METRO GOLDEN MEDICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
METRO GOLDEN MEDICAL, LLC
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:
UROGUIDANCE, LLC
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:
1649329368
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 932746
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44193-2746
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-548-3063
Provider Business Mailing Address Fax Number:
937-548-1371

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
414 OAKWOOD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAKWOOD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45409-2217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-548-3063
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/10/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RUSSELL
Authorized Official First Name:
RAYMOND
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
937-367-4637

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  35073039 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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