1033388558 NPI number — EDISON LAKES UROLOGY PLYMOUTH OFFICE

Table of content: (NPI 1033388558)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033388558 NPI number — EDISON LAKES UROLOGY PLYMOUTH OFFICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDISON LAKES UROLOGY PLYMOUTH OFFICE
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:
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:
1033388558
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
303 S NAPPANEE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELKHART
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46514-2066
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-296-3200
Provider Business Mailing Address Fax Number:
574-296-3300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1919 LAKE AVE
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46563-7830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-935-2138
Provider Business Practice Location Address Fax Number:
574-935-2136
Provider Enumeration Date:
02/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BUSBY
Authorized Official First Name:
DARRYL
Authorized Official Middle Name:
R
Authorized Official Title or Position:
EXECUTIVE ADMINISTRATOR
Authorized Official Telephone Number:
574-296-3200

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)





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