Provider Demographics
NPI:1033388558
Name:EDISON LAKES UROLOGY PLYMOUTH OFFICE
Entity Type:Organization
Organization Name:EDISON LAKES UROLOGY PLYMOUTH OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BUSBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-296-3200
Mailing Address - Street 1:303 S NAPPANEE ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-2066
Mailing Address - Country:US
Mailing Address - Phone:574-296-3200
Mailing Address - Fax:574-296-3300
Practice Address - Street 1:1919 LAKE AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-7830
Practice Address - Country:US
Practice Address - Phone:574-935-2138
Practice Address - Fax:574-935-2136
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELKHART CLINIC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-28
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty