Provider Demographics
NPI:1093901340
Name:ADVANCED UROLOGIC SURGEONS PC
Entity Type:Organization
Organization Name:ADVANCED UROLOGIC SURGEONS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOWLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-244-4060
Mailing Address - Street 1:604 SEVILLE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-7001
Mailing Address - Country:US
Mailing Address - Phone:618-244-4060
Mailing Address - Fax:618-244-4061
Practice Address - Street 1:604 SEVILLE DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-7001
Practice Address - Country:US
Practice Address - Phone:618-244-4060
Practice Address - Fax:618-244-4061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114878174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDE2609OtherRAILROAD
IL212938Medicare PIN
ILDE2609OtherRAILROAD