Provider Demographics
NPI:1336514389
Name:TRI-STATE UROLOGY, P.C.
Entity Type:Organization
Organization Name:TRI-STATE UROLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:W
Authorized Official - Last Name:REEVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-793-9564
Mailing Address - Street 1:4300 W MAIN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1054
Mailing Address - Country:US
Mailing Address - Phone:334-793-9564
Mailing Address - Fax:334-671-8907
Practice Address - Street 1:4300 W MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1054
Practice Address - Country:US
Practice Address - Phone:334-793-9564
Practice Address - Fax:334-671-8907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL7831208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty