Provider Demographics
NPI:1508886805
Name:UROLOGY PROFESSIONAL ASSOC
Entity Type:Organization
Organization Name:UROLOGY PROFESSIONAL ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-432-0700
Mailing Address - Street 1:499 GLOSTER CREEK VILLAGE
Mailing Address - Street 2:SUITE A1
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4934
Mailing Address - Country:US
Mailing Address - Phone:662-377-7100
Mailing Address - Fax:662-377-7115
Practice Address - Street 1:499 GLOSTER CREEK VILLAGE
Practice Address - Street 2:SUITE A1
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4600
Practice Address - Country:US
Practice Address - Phone:662-377-7118
Practice Address - Fax:662-377-7115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2023-09-21
Deactivation Date:2023-09-13
Deactivation Code:
Reactivation Date:2023-09-21
Provider Licenses
StateLicense IDTaxonomies
MS208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09011122Medicaid
MS=========OtherBLUE CROSS OF MISSISSIPPI
ALG694Medicare PIN
MS09011122Medicaid