Provider Demographics
NPI:1508023896
Name:LIMA MEMORIAL PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LIMA MEMORIAL PROFESSIONAL CORPORATION
Other - Org Name:LIMA MEMORIAL DIABETIC CENTER AT MEDPARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR IF 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 1:525 N EASTOWN RD STE A
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45807-2268
Practice Address - Country:US
Practice Address - Phone:419-998-8291
Practice Address - Fax:419-998-8292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1457474900OtherGROUP NPI
OH2223703Medicaid