Provider Demographics
NPI:1770685588
Name:EAST ALABAMA UROLOGY ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:EAST ALABAMA UROLOGY ASSOCIATES, P.A.
Other - Org Name:EAST ALABAMA UROLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-749-8146
Mailing Address - Street 1:121 N 20TH ST STE 19
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-5456
Mailing Address - Country:US
Mailing Address - Phone:334-749-8146
Mailing Address - Fax:334-737-6432
Practice Address - Street 1:121 N 20TH ST STE 19
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-5456
Practice Address - Country:US
Practice Address - Phone:334-749-8146
Practice Address - Fax:334-737-6432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529700320Medicaid
AL0769290001Medicare NSC
AL529700320Medicaid
ALCD4553Medicare PIN