Provider Demographics
NPI:1619065620
Name:DAVIDSON UROLOGY, PA
Entity Type:Organization
Organization Name:DAVIDSON UROLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:MARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-248-4413
Mailing Address - Street 1:106 W MEDICAL PARK DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27292-6853
Mailing Address - Country:US
Mailing Address - Phone:336-248-4413
Mailing Address - Fax:336-248-6260
Practice Address - Street 1:106 W MEDICAL PARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-6853
Practice Address - Country:US
Practice Address - Phone:336-248-4413
Practice Address - Fax:336-248-6260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39444208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC47333OtherMEDCOST
NCDA6062OtherRAILROAD MEDCIARE
NC017UWOtherBCBS, NC
NC1638OtherPARTNERS MEDICARE
NC8953944Medicaid
NC2335492Medicare ID - Type Unspecified