Provider Demographics
NPI:1407154925
Name:LIMA MEMORIAL PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LIMA MEMORIAL PROFESSIONAL CORPORATION
Other - Org Name:HANNA FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF LMP
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:UTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-998-4668
Mailing Address - Street 1:1001 BELLEFONTAINE AVE
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2800
Mailing Address - Country:US
Mailing Address - Phone:419-998-4575
Mailing Address - Fax:419-998-4586
Practice Address - Street 1:1005 BELLEFONTAINE AVE STE 340
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2876
Practice Address - Country:US
Practice Address - Phone:419-227-3077
Practice Address - Fax:419-224-1667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-08
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207Q00000X
OHOH-RN253331363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1457474900OtherNPI
OH2223703Medicaid
OH2223703Medicaid