Provider Demographics
NPI:1750486734
Name:MOUNTAINCARE UROLOGY
Entity Type:Organization
Organization Name:MOUNTAINCARE UROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARCHUK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-586-7820
Mailing Address - Street 1:PO BOX 1052
Mailing Address - Street 2:
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779-1052
Mailing Address - Country:US
Mailing Address - Phone:828-586-7820
Mailing Address - Fax:828-586-7821
Practice Address - Street 1:81 MEDICAL PARK LOOP
Practice Address - Street 2:SUITE 204
Practice Address - City:SYLVA
Practice Address - State:NC
Practice Address - Zip Code:28779-5291
Practice Address - Country:US
Practice Address - Phone:828-586-7820
Practice Address - Fax:828-586-7821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC018W0OtherBLUE CROSS
NC5905746Medicaid
NC018W0OtherBLUE CROSS