Healthcare Provider Details

I. General information

NPI: 1093972614
Provider Name (Legal Business Name): LIMA MEMORIAL PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 04/09/2022
Certification Date: 04/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 BELLEFONTAINE AVE STE 245
LIMA OH
45804-2884
US

IV. Provider business mailing address

1001 BELLEFONTAINE AVE
LIMA OH
45804-2800
US

V. Phone/Fax

Practice location:
  • Phone: 419-998-8230
  • Fax: 419-998-8231
Mailing address:
  • Phone: 419-998-4575
  • Fax: 419-998-4586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2223703
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer
# 2
Identifier1457474900
Identifier TypeOTHER
Identifier StateOH
Identifier IssuerGROUP NPI

VIII. Authorized Official

Name: JEFFREY UTZ
Title or Position: DIRECTOR OF LMP
Credential:
Phone: 419-998-4668