Provider Demographics
NPI:1093973836
Name:UROLOGY GROUP PC
Entity Type:Organization
Organization Name:UROLOGY GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:A
Authorized Official - Last Name:EDDLESTONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-271-2272
Mailing Address - Street 1:401 SOUTHCREST CIR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-6726
Mailing Address - Country:US
Mailing Address - Phone:662-349-4329
Mailing Address - Fax:
Practice Address - Street 1:401 SOUTHCREST CIR
Practice Address - Street 2:SUITE 201
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671
Practice Address - Country:US
Practice Address - Phone:662-349-4329
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09070511Medicaid
CL4147Medicare PIN
MSC00393Medicare PIN