Provider Demographics
NPI:1760676357
Name:TRI STATE UROLOGIC SERVICES PSC
Entity Type:Organization
Organization Name:TRI STATE UROLOGIC SERVICES PSC
Other - Org Name:THE UROLOGY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:EARL
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-366-4000
Mailing Address - Street 1:4700 SMITH RD
Mailing Address - Street 2:SUITE L
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2787
Mailing Address - Country:US
Mailing Address - Phone:513-366-4000
Mailing Address - Fax:513-366-4001
Practice Address - Street 1:5714 C SIGNAL DR
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150
Practice Address - Country:US
Practice Address - Phone:513-366-4000
Practice Address - Fax:513-366-4001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9345021Medicare PIN