1902982051 NPI number — UROLOGY ASSOCIATES MEDICAL GROUP, PC

Table of content: (NPI 1902982051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902982051 NPI number — UROLOGY ASSOCIATES MEDICAL GROUP, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UROLOGY ASSOCIATES MEDICAL 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:
1902982051
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12890
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
83002-2890
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-733-7460
Provider Business Mailing Address Fax Number:
307-733-7482

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 EAST BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
83001-9998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-733-7460
Provider Business Practice Location Address Fax Number:
307-733-7482
Provider Enumeration Date:
10/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LOWE
Authorized Official First Name:
PHILLIP
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
307-733-7460

Provider Taxonomy Codes

  • Taxonomy code: 2088P0231X , with the licence number:  6215A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X , with the licence number: 6215A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 114954700 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 806684400 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 118827500 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 806233600 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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