MEDICARE: PROVIDENCE UROLOGY, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist		NC
2	208800000X	Urology Physician	200101464	NC
3	208800000X	Urology Physician	200000981	NC

General Provider Information

NPI Number	:	1255537403
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE UROLOGY, PLLC

Provider Business Mailing Address
First Line	:	1428 ELLEN ST
Second Line	:	SUITE A
City	:	MONROE
State	:	NC
Zip	:	28112-5285
Country	:	US
Telephone Number	:	704-289-4361
Fax Number	:	704-283-4705

Provider Business Practice Location Address
First Line	:	1428 ELLEN ST
Second Line	:	SUITE A
City	:	MONROE
State	:	NC
Zip	:	28112-5285
Country	:	US
Telephone Number	:	704-289-4361
Fax Number	:	704-283-4705

Authorized Official
Title or Position	:	PHYSICIAN/CO-OWNER
Name	:	MR. ARTHUR J. LIM
Credential	:	M.D.
Telephone Number	:	704-289-4361

Provider Enumeration Date	:	06/25/2007
Last Update Date	:	07/21/2022

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