Provider Demographics
NPI:1720798101
Name:WEST CENTRAL OHIO UROLOGICAL CENTERS OF EXCELLENCE, LLC
Entity Type:Organization
Organization Name:WEST CENTRAL OHIO UROLOGICAL CENTERS OF EXCELLENCE, LLC
Other - Org Name:CROSSROADS UROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, MD
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-855-5119
Mailing Address - Street 1:1365 SHOREVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-3684
Mailing Address - Country:US
Mailing Address - Phone:419-855-5119
Mailing Address - Fax:419-614-6027
Practice Address - Street 1:2751 FORT AMANDA RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-4805
Practice Address - Country:US
Practice Address - Phone:419-855-5119
Practice Address - Fax:419-614-6027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-28
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty