Provider Demographics
NPI:1043338502
Name:HEART OF GEORGIA UROLOGY ASSOCIATES,LLC
Entity Type:Organization
Organization Name:HEART OF GEORGIA UROLOGY ASSOCIATES,LLC
Other - Org Name:MIDDLE GEORGIA UROLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLAIRE
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-272-6150
Mailing Address - Street 1:200 FAIRVIEW PARK DR
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2547
Mailing Address - Country:US
Mailing Address - Phone:478-272-6150
Mailing Address - Fax:478-272-4903
Practice Address - Street 1:200 FAIRVIEW PARK DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2547
Practice Address - Country:US
Practice Address - Phone:478-272-6150
Practice Address - Fax:478-272-4903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7136Medicare ID - Type Unspecified