Healthcare Provider Details

I. General information

NPI: 1255537403
Provider Name (Legal Business Name): PROVIDENCE UROLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 ELLEN ST SUITE A
MONROE NC
28112-5285
US

IV. Provider business mailing address

1428 ELLEN ST SUITE A
MONROE NC
28112-5285
US

V. Phone/Fax

Practice location:
  • Phone: 704-289-4361
  • Fax: 704-283-4705
Mailing address:
  • Phone: 704-289-4361
  • Fax: 704-283-4705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number200101464
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number200000981
License Number StateNC

VIII. Authorized Official

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