Provider Demographics
NPI:1255537403
Name:PROVIDENCE UROLOGY, PLLC
Entity type:Organization
Organization Name:PROVIDENCE UROLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:J
Authorized Official - Last Name:LIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-289-4361
Mailing Address - Street 1:1428 ELLEN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-5285
Mailing Address - Country:US
Mailing Address - Phone:704-289-4361
Mailing Address - Fax:704-283-4705
Practice Address - Street 1:1428 ELLEN ST
Practice Address - Street 2:SUITE A
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-5285
Practice Address - Country:US
Practice Address - Phone:704-289-4361
Practice Address - Fax:704-283-4705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC174400000X
NC200101464208800000X
NC200000981208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC=========OtherTAX IDENTIFIER