Provider Demographics
NPI:1114942927
Name:CAROLINA UROLOGY CENTER, PA
Entity Type:Organization
Organization Name:CAROLINA UROLOGY CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-327-1116
Mailing Address - Street 1:1780 MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1194
Mailing Address - Country:US
Mailing Address - Phone:803-327-1116
Mailing Address - Fax:803-327-6872
Practice Address - Street 1:10620 PARK RD
Practice Address - Street 2:SUITE 218
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8472
Practice Address - Country:US
Practice Address - Phone:704-543-7186
Practice Address - Fax:704-543-7094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC02555OtherBC/BS
NC0127VOtherBCBS
NC890127VMedicaid
NC02555OtherBC/BS
NC2316040Medicare PIN