Provider Demographics
NPI:1417137167
Name:PROGRESSIVE UROLOGY, PC
Entity Type:Organization
Organization Name:PROGRESSIVE UROLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CAREY
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:RANSONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-324-3120
Mailing Address - Street 1:1505 STATE ST
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:IN
Mailing Address - Zip Code:46350-3115
Mailing Address - Country:US
Mailing Address - Phone:219-324-3120
Mailing Address - Fax:219-362-3743
Practice Address - Street 1:1505 STATE ST
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3115
Practice Address - Country:US
Practice Address - Phone:219-324-3120
Practice Address - Fax:219-362-3743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-10
Last Update Date:2007-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045023208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200091080Medicaid
IN200091080Medicaid
IN659670Medicare PIN