1093973836 NPI number — UROLOGY GROUP PC

Table of content: (NPI 1093973836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093973836 NPI number — UROLOGY GROUP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UROLOGY GROUP PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093973836
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 SOUTHCREST CIR
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
SOUTHAVEN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38671-6726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-349-4329
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 SOUTHCREST CIR
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-349-4329
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
EDDLESTONE
Authorized Official First Name:
DEBORAH
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CONSULTANT
Authorized Official Telephone Number:
901-271-2272

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 09070511 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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