Provider Demographics
NPI:1619927100
Name:DANVILLE UROLOGIC CLINIC INC
Entity Type:Organization
Organization Name:DANVILLE UROLOGIC CLINIC INC
Other - Org Name:SOUTHSIDE UROLOGY & NEPHROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:M
Authorized Official - Last Name:CARBONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-792-1433
Mailing Address - Street 1:1040 MAIN ST
Mailing Address - Street 2:P.O. BOX 1360
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-1816
Mailing Address - Country:US
Mailing Address - Phone:434-792-1433
Mailing Address - Fax:434-797-2807
Practice Address - Street 1:1040 MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-1816
Practice Address - Country:US
Practice Address - Phone:434-792-1433
Practice Address - Fax:434-797-2807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207RN0300X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA171773OtherANTHEM GROUP NUMBER
NC89016RWMedicaid
VADC7953OtherRAILROAD MEDICARE
NC89016RWMedicaid
VA171773OtherANTHEM GROUP NUMBER