Provider Demographics
NPI: | 1376649830 |
---|---|
Name: | ATLANTIC UROLOGY PC |
Entity Type: | Organization |
Organization Name: | ATLANTIC UROLOGY PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER M.D |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | RICHARD |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | MYNATT |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 910-362-8765 |
Mailing Address - Street 1: | PO BOX 30727 |
Mailing Address - Street 2: | |
Mailing Address - City: | CHARLOTTE |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 28230-0727 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 910-362-8765 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 20 MEDICAL CAMPUS DR |
Practice Address - Street 2: | SUITE 202 |
Practice Address - City: | SUPPLY |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28462-4096 |
Practice Address - Country: | US |
Practice Address - Phone: | 910-362-8765 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-09-15 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
2344726 | Medicare ID - Type Unspecified |