Provider Demographics
NPI:1578689253
Name:JOHNSON CITY UROLOGICAL CLINIC, P.C.
Entity Type:Organization
Organization Name:JOHNSON CITY UROLOGICAL CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:D
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-926-6112
Mailing Address - Street 1:2340 KNOB CREEK ROAD
Mailing Address - Street 2:SUITE 720
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2977
Mailing Address - Country:US
Mailing Address - Phone:423-926-6112
Mailing Address - Fax:423-434-0278
Practice Address - Street 1:2340 KNOB CREEK ROAD
Practice Address - Street 2:SUITE 720
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2977
Practice Address - Country:US
Practice Address - Phone:423-926-6112
Practice Address - Fax:423-434-0278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3172410Medicaid
TNH58881Medicare UPIN
TN3329892Medicare ID - Type Unspecified
TNG70839Medicare UPIN
TN3875502Medicare ID - Type Unspecified
TN3375873Medicare ID - Type Unspecified
TN3172410Medicaid
TNI32522Medicare UPIN
TN3172411Medicare ID - Type Unspecified
TN3852420Medicare ID - Type Unspecified