1083807093 NPI number — TRI STATE UROLOGIC SERVICES PSC INC

Table of content: (NPI 1083807093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083807093 NPI number — TRI STATE UROLOGIC SERVICES PSC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI STATE UROLOGIC SERVICES PSC INC
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:
Provider Other Organization Name Type Code:
6
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:
1083807093
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 JOSEPH E SANKER BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45212-1979
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-841-7400
Provider Business Mailing Address Fax Number:
513-841-7402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
605 WILSON CREEK RD
Provider Second Line Business Practice Location Address:
SUITE 01
Provider Business Practice Location Address City Name:
LAWRENCEBURG
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47025-2506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-363-2200
Provider Business Practice Location Address Fax Number:
859-363-2201
Provider Enumeration Date:
08/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WALZ
Authorized Official First Name:
EARL
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
513-841-7400

Provider Taxonomy Codes

  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200091770A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: DN9528 . This is a "RAIROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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