1376593061 NPI number — PEDIATRIC UROLOGY ASSOCIATES

Table of content: (NPI 1376593061)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376593061 NPI number — PEDIATRIC UROLOGY ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC UROLOGY ASSOCIATES
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:
6
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:
1376593061
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3135 SPRINGBANK LANE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28226-3360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-540-3667
Provider Business Mailing Address Fax Number:
704-540-3668

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3135 SPRINGBANK LANE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28226-3360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-540-3667
Provider Business Practice Location Address Fax Number:
704-540-3668
Provider Enumeration Date:
05/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MOLITIESM
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
407-540-3667

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  1000392 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 103556 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: 9600282 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 51818 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02367 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8951818 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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