Provider Demographics
NPI:1619919917
Name:SOUTHERN UROLOGY ASSOCIATES LLC
Entity Type:Organization
Organization Name:SOUTHERN UROLOGY ASSOCIATES LLC
Other - Org Name:SOUTHERN UROLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:LAGEESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-988-7044
Mailing Address - Street 1:15190 COMMUNITY RD
Mailing Address - Street 2:SUITE 260
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3485
Mailing Address - Country:US
Mailing Address - Phone:228-539-0071
Mailing Address - Fax:228-539-0722
Practice Address - Street 1:15190 COMMUNITY RD
Practice Address - Street 2:SUITE 260
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3485
Practice Address - Country:US
Practice Address - Phone:228-539-0071
Practice Address - Fax:228-539-0722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1275576Medicaid
MS=========OtherTAX ID