Provider Demographics
NPI:1215966858
Name:LIM, EDISON UY (MD)
Entity type:Individual
Prefix:
First Name:EDISON
Middle Name:UY
Last Name:LIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1572 S BELL SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:CHERRY VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61016-9362
Mailing Address - Country:US
Mailing Address - Phone:815-332-3015
Mailing Address - Fax:815-332-7805
Practice Address - Street 1:1572 S BELL SCHOOL RD
Practice Address - Street 2:
Practice Address - City:CHERRY VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61016-9362
Practice Address - Country:US
Practice Address - Phone:815-332-3015
Practice Address - Fax:815-332-7805
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090152207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL553180OtherMEDICARE GROUP #
IL036090152Medicaid
IL080099725Medicare ID - Type UnspecifiedRR INDIVIDUAL #
IL553180OtherMEDICARE GROUP #
ILG15618Medicare UPIN
ILCC5050Medicare ID - Type UnspecifiedRR MEDICARE GROUP #
ILL63316Medicare ID - Type Unspecified
IL553180005Medicare PIN
IL801570Medicare ID - Type UnspecifiedMEDICARE GROUP #