Provider Demographics
NPI:1164537635
Name:SUMTER UROLOGICAL, LLC
Entity Type:Organization
Organization Name:SUMTER UROLOGICAL, LLC
Other - Org Name:SUMTER UROLOGICAL ASSOCIATES, PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESEDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-469-4402
Mailing Address - Street 1:410 W WESMARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-1983
Mailing Address - Country:US
Mailing Address - Phone:803-469-4402
Mailing Address - Fax:803-469-4473
Practice Address - Street 1:410 W WESMARK BLVD
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1983
Practice Address - Country:US
Practice Address - Phone:803-469-4402
Practice Address - Fax:803-469-4473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA0276Medicaid
SCPA0276Medicaid