Provider Demographics
NPI:1083831804
Name:COOSA VALLEY UROLOGY, P.C.
Entity Type:Organization
Organization Name:COOSA VALLEY UROLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAMOUN
Authorized Official - Middle Name:R
Authorized Official - Last Name:PACHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-245-2269
Mailing Address - Street 1:16 SOUTH DOUGLAS AVENUE
Mailing Address - Street 2:
Mailing Address - City:SYLACAUGA
Mailing Address - State:AL
Mailing Address - Zip Code:35150
Mailing Address - Country:US
Mailing Address - Phone:256-245-2269
Mailing Address - Fax:256-245-2260
Practice Address - Street 1:16 SOUTH DOUGLAS AVENUE
Practice Address - Street 2:
Practice Address - City:SYLACAUGA
Practice Address - State:AL
Practice Address - Zip Code:35150
Practice Address - Country:US
Practice Address - Phone:256-245-2269
Practice Address - Fax:256-245-2260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL8767174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529603840Medicaid
AL340007817OtherRAILROAD MEDICARE
AL1910002OtherUNITED HEALTH CARE
AL000005604Medicare PIN
AL1910002OtherUNITED HEALTH CARE
AL0522500001Medicare NSC