Provider Demographics
NPI:1386630408
Name:GREENBRIER VALLEY UROLOGY ASSOCIATES, INC
Entity Type:Organization
Organization Name:GREENBRIER VALLEY UROLOGY ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:F
Authorized Official - Last Name:FORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-647-5642
Mailing Address - Street 1:119 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RONCEVERTE
Mailing Address - State:WV
Mailing Address - Zip Code:24970-9737
Mailing Address - Country:US
Mailing Address - Phone:304-647-5642
Mailing Address - Fax:304-647-5644
Practice Address - Street 1:119 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-9737
Practice Address - Country:US
Practice Address - Phone:304-647-5642
Practice Address - Fax:304-647-5644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC08401Medicare PIN