Provider Demographics
NPI:1750487872
Name:GAINESVILLE UROLOGY CENTER PA
Entity Type:Organization
Organization Name:GAINESVILLE UROLOGY CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:GADDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-373-6338
Mailing Address - Street 1:4881 NW 8TH AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4582
Mailing Address - Country:US
Mailing Address - Phone:352-373-6338
Mailing Address - Fax:352-373-6144
Practice Address - Street 1:4881 NW 8TH AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4582
Practice Address - Country:US
Practice Address - Phone:352-373-6338
Practice Address - Fax:352-373-6144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0048155208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL43583OtherBCBS FL GROUP NUMBER
FL43583OtherBCBS FL GROUP NUMBER