Provider Demographics
NPI:1053509513
Name:TRI-COUNTY UROLOGY INC
Entity Type:Organization
Organization Name:TRI-COUNTY UROLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:H
Authorized Official - Last Name:RUDICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-781-8669
Mailing Address - Street 1:761 JOHNSONBURG RD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:SAINT MARYS
Mailing Address - State:PA
Mailing Address - Zip Code:15857-3483
Mailing Address - Country:US
Mailing Address - Phone:814-781-8669
Mailing Address - Fax:814-781-8671
Practice Address - Street 1:761 JOHNSONBURG RD
Practice Address - Street 2:SUITE 350
Practice Address - City:SAINT MARYS
Practice Address - State:PA
Practice Address - Zip Code:15857-3483
Practice Address - Country:US
Practice Address - Phone:814-781-8669
Practice Address - Fax:814-781-8671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD056864L208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019212650001Medicaid
PA0019212650001Medicaid