Provider Demographics
NPI:1588694814
Name:EXECUTIVE UROLOGY
Entity type:Organization
Organization Name:EXECUTIVE UROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:RICE
Authorized Official - Suffix:
Authorized Official - Credentials:MC
Authorized Official - Phone:419-627-8771
Mailing Address - Street 1:2800 HAYES AVENUE
Mailing Address - Street 2:BLDG D
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870
Mailing Address - Country:US
Mailing Address - Phone:419-627-8771
Mailing Address - Fax:419-627-0363
Practice Address - Street 1:2800 HAYES AVE
Practice Address - Street 2:BLDG D
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-7248
Practice Address - Country:US
Practice Address - Phone:419-627-8771
Practice Address - Fax:419-627-0363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2274793Medicaid
OH2281972Medicaid
OHCG9157OtherRAILROAD MEDICARE
OH2282328Medicaid
OH9289582Medicare PIN
OH2282328Medicaid
OH9289583Medicare PIN