Provider Demographics
NPI:1558537704
Name:UPPER MIAMI VALLEY UROLOGY CLINIC, INC.
Entity Type:Organization
Organization Name:UPPER MIAMI VALLEY UROLOGY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRGILIO
Authorized Official - Middle Name:A
Authorized Official - Last Name:PONFERRADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-773-7083
Mailing Address - Street 1:PO BOX 1719
Mailing Address - Street 2:
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356-4719
Mailing Address - Country:US
Mailing Address - Phone:937-773-7083
Mailing Address - Fax:937-773-9716
Practice Address - Street 1:9163 N COUNTY ROAD 25A
Practice Address - Street 2:
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356-4524
Practice Address - Country:US
Practice Address - Phone:937-773-7083
Practice Address - Fax:937-773-9716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH037425174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0746803Medicaid
OH9184192Medicare PIN