Provider Demographics
NPI:1407564263
Name:SOUTHERN UROLOGY LLC
Entity Type:Organization
Organization Name:SOUTHERN UROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:ELDREDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-769-7779
Mailing Address - Street 1:1307 CROWLEY RAYNE HWY
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:LA
Mailing Address - Zip Code:70526-8210
Mailing Address - Country:US
Mailing Address - Phone:337-232-4555
Mailing Address - Fax:
Practice Address - Street 1:1307 CROWLEY RAYNE HWY
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526-8210
Practice Address - Country:US
Practice Address - Phone:337-232-4555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN UROLOGY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty