Provider Demographics
NPI:1194836239
Name:CHILDRENS UROLOGY GROUP PL
Entity Type:Organization
Organization Name:CHILDRENS UROLOGY GROUP PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLLNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-874-7500
Mailing Address - Street 1:4712 N ARMENIA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-2611
Mailing Address - Country:US
Mailing Address - Phone:813-874-7500
Mailing Address - Fax:813-877-1397
Practice Address - Street 1:4712 N ARMENIA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-2611
Practice Address - Country:US
Practice Address - Phone:813-874-7500
Practice Address - Fax:813-877-1397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11750ZMedicare PIN
FLAM517ZMedicare PIN
FL30513YMedicare PIN
FL27378ZMedicare PIN
FL35990ZMedicare PIN