Healthcare Provider Details

I. General information

NPI: 1104190578
Provider Name (Legal Business Name): LIMA MEMORIAL PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 MICHIGAN ST STE 203
SIDNEY OH
45365-2401
US

IV. Provider business mailing address

1001 BELLEFONTAINE AVE
LIMA OH
45804-2800
US

V. Phone/Fax

Practice location:
  • Phone: 937-492-3351
  • Fax: 937-492-8631
Mailing address:
  • Phone: 419-998-4575
  • Fax: 419-998-4586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

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