MEDICARE: PBM UROLOGY LTD

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	208800000X	Urology Physician		IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	993660	OTHER	IL	MEDICARE ID

General Provider Information

NPI Number	:	1447321781
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PBM UROLOGY LTD

Provider Business Mailing Address
First Line	:	1215 S 4TH ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62703-2259
Country	:	US
Telephone Number	:	217-528-7306
Fax Number	:

Provider Business Practice Location Address
First Line	:	1215 S 4TH ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62703-2259
Country	:	US
Telephone Number	:	217-528-7306
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	EUGENE DIXON
Credential	:	M.D.
Telephone Number	:	217-528-7306

Provider Enumeration Date	:	11/10/2006
Last Update Date	:	10/22/2007

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