Provider Demographics
NPI:1376593061
Name:PEDIATRIC UROLOGY ASSOCIATES
Entity Type:Organization
Organization Name:PEDIATRIC UROLOGY ASSOCIATES
Other - Org Name:PEDIATRIC UROLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOLITIESM
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:407-540-3667
Mailing Address - Street 1:3135 SPRINGBANK LANE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-3360
Mailing Address - Country:US
Mailing Address - Phone:704-540-3667
Mailing Address - Fax:704-540-3668
Practice Address - Street 1:3135 SPRINGBANK LANE
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-3360
Practice Address - Country:US
Practice Address - Phone:704-540-3667
Practice Address - Fax:704-540-3668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600282208800000X
NC1000392363AM0700X
NC103556363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC51818Medicaid
NC02367OtherBCBS
NC8951818Medicaid
NC51818Medicaid