Provider Demographics
NPI:1508892266
Name:GREENVILLE UROLOGY, PA
Entity Type:Organization
Organization Name:GREENVILLE UROLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:CLINTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-605-8541
Mailing Address - Street 1:52 BEAR DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4458
Mailing Address - Country:US
Mailing Address - Phone:864-295-2131
Mailing Address - Fax:864-605-8556
Practice Address - Street 1:52 BEAR DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4458
Practice Address - Country:US
Practice Address - Phone:864-295-2131
Practice Address - Fax:864-605-8556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2427Medicaid
SCGP2427Medicaid