Provider Demographics
NPI:1215209416
Name:COLQUITT REGIONAL UROLOGY, LLC
Entity Type:Organization
Organization Name:COLQUITT REGIONAL UROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JAYSHREE
Authorized Official - Middle Name:
Authorized Official - Last Name:BHAVNANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-891-9131
Mailing Address - Street 1:PO BOX 2876
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-2876
Mailing Address - Country:US
Mailing Address - Phone:229-891-9148
Mailing Address - Fax:
Practice Address - Street 1:115 31ST AVE SE
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6771
Practice Address - Country:US
Practice Address - Phone:229-891-9148
Practice Address - Fax:229-217-4910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-02
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA67024208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G701316OtherMEDICARE