Provider Demographics
NPI:1508038977
Name:CROSSROADS UROLOGY
Entity Type:Organization
Organization Name:CROSSROADS UROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:ST.JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-621-1880
Mailing Address - Street 1:785 OHIO AVE
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-6217
Mailing Address - Country:US
Mailing Address - Phone:662-621-1880
Mailing Address - Fax:662-621-1882
Practice Address - Street 1:785 OHIO AVE
Practice Address - Street 2:SUITE 1B
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-6217
Practice Address - Country:US
Practice Address - Phone:662-621-1880
Practice Address - Fax:662-621-1882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20046174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty