Provider Demographics
NPI:1013925965
Name:CHAMPION UROLOGY LTD
Entity Type:Organization
Organization Name:CHAMPION UROLOGY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:LIN
Authorized Official - Last Name:LUTZEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-596-0964
Mailing Address - Street 1:35 WELLS ST
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-2922
Mailing Address - Country:US
Mailing Address - Phone:401-596-0964
Mailing Address - Fax:401-596-8634
Practice Address - Street 1:35 WELLS STREET
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891
Practice Address - Country:US
Practice Address - Phone:401-596-0964
Practice Address - Fax:401-596-8634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI7511208800000X
RI10831208800000X
CT040289208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003114204Medicaid
RICU43922Medicaid
H30972Medicare UPIN
RI349023512Medicare PIN
CT3490000349Medicare PIN
CT003114204Medicaid