Provider Demographics
NPI:1578630398
Name:EDENTON UROLOGY CLINIC
Entity Type:Organization
Organization Name:EDENTON UROLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:CRIST
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-482-1606
Mailing Address - Street 1:210 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-1904
Mailing Address - Country:US
Mailing Address - Phone:252-482-1606
Mailing Address - Fax:252-482-1611
Practice Address - Street 1:210 N BROAD ST
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932
Practice Address - Country:US
Practice Address - Phone:252-482-1606
Practice Address - Fax:252-482-1611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900331208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0289TOtherBCBS
NC790289TMedicaid
NC790289TMedicaid