Provider Demographics
NPI:1407872872
Name:GAINESVILLE UROLOGY, PC
Entity Type:Organization
Organization Name:GAINESVILLE UROLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:E
Authorized Official - Last Name:BAUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-532-8227
Mailing Address - Street 1:1240 JESSE JEWELL PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3862
Mailing Address - Country:US
Mailing Address - Phone:770-532-8438
Mailing Address - Fax:770-535-1785
Practice Address - Street 1:1240 JESSE JEWELL PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3862
Practice Address - Country:US
Practice Address - Phone:770-532-8438
Practice Address - Fax:770-535-1785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0685640001Medicare NSC