Provider Demographics
NPI:1104026160
Name:KOKOMO UROLOGY INC.
Entity Type:Organization
Organization Name:KOKOMO UROLOGY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:PEELLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-455-4075
Mailing Address - Street 1:2345 W LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-8012
Mailing Address - Country:US
Mailing Address - Phone:765-455-4075
Mailing Address - Fax:765-455-4094
Practice Address - Street 1:2345 W LINCOLN RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-8012
Practice Address - Country:US
Practice Address - Phone:765-455-4075
Practice Address - Fax:765-455-4094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100136840AMedicaid
IN0249010001Medicare NSC