Provider Demographics
NPI:1558788646
Name:LIMA MEMORIAL PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LIMA MEMORIAL PROFESSIONAL CORPORATION
Other - Org Name:INDIAN LAKE MEDICAL CENTER
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 1:322 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLS POINT
Practice Address - State:OH
Practice Address - Zip Code:43348-9601
Practice Address - Country:US
Practice Address - Phone:937-842-2318
Practice Address - Fax:937-842-2414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-26
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1457474900OtherGROUP NPI
OH2223703Medicaid
OH9311764Medicare PIN