Provider Demographics
NPI:1326153677
Name:CLEVELAND UROLOGIC SURGERY, PA
Entity Type:Organization
Organization Name:CLEVELAND UROLOGIC SURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SHEM
Authorized Official - Middle Name:K
Authorized Official - Last Name:BLACKLEY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:704-482-2011
Mailing Address - Street 1:PO BOX 1029
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28151-1029
Mailing Address - Country:US
Mailing Address - Phone:704-482-2011
Mailing Address - Fax:704-484-0303
Practice Address - Street 1:1001 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-1800
Practice Address - Country:US
Practice Address - Phone:704-482-2011
Practice Address - Fax:704-484-0303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC230126OtherMEDICARE PTAN
NC230126Medicare PIN