Provider Demographics
NPI:1528066602
Name:UROLOGIC PHYSICIANS & SURGEONS INC.
Entity type:Organization
Organization Name:UROLOGIC PHYSICIANS & SURGEONS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:R
Authorized Official - Last Name:PENCE
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:937-429-7352
Mailing Address - Street 1:2145 N FAIRFIELD RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-2580
Mailing Address - Country:US
Mailing Address - Phone:937-429-7352
Mailing Address - Fax:937-429-3772
Practice Address - Street 1:2145 N FAIRFIELD RD
Practice Address - Street 2:SUITE B
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-2580
Practice Address - Country:US
Practice Address - Phone:937-429-7352
Practice Address - Fax:937-429-3772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2426100Medicaid
OH2426100Medicaid