Provider Demographics
NPI:1598925638
Name:PREMIER UROLOGY CORP
Entity Type:Organization
Organization Name:PREMIER UROLOGY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-818-0215
Mailing Address - Street 1:430 ALTAIR PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-7647
Mailing Address - Country:US
Mailing Address - Phone:614-818-0215
Mailing Address - Fax:614-818-0217
Practice Address - Street 1:430 ALTAIR PKWY STE 200
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-7647
Practice Address - Country:US
Practice Address - Phone:614-818-0215
Practice Address - Fax:614-818-0217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-12
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-075512208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2334094Medicaid
OH7674368OtherAETNA