Provider Demographics
NPI:1235311556
Name:UROLOGY CLINIC, SC
Entity Type:Organization
Organization Name:UROLOGY CLINIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:715-295-9939
Mailing Address - Street 1:PO BOX 8031
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-8031
Mailing Address - Country:US
Mailing Address - Phone:920-996-1345
Mailing Address - Fax:920-739-0124
Practice Address - Street 1:500 VINCENT ST
Practice Address - Street 2:SUITE D
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-1848
Practice Address - Country:US
Practice Address - Phone:715-295-9939
Practice Address - Fax:715-295-9946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36770-20208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32166500Medicaid
WI32166500Medicaid
WI6257680001Medicare NSC