Provider Demographics
NPI:1790131522
Name:UROLOGY CLINIC AT CAROLINAS
Entity Type:Organization
Organization Name:UROLOGY CLINIC AT CAROLINAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:RABON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-674-1670
Mailing Address - Street 1:1594 FREEDOM BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-6046
Mailing Address - Country:US
Mailing Address - Phone:843-674-1670
Mailing Address - Fax:843-674-4707
Practice Address - Street 1:1594 FREEDOM BLVD STE 203
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-6046
Practice Address - Country:US
Practice Address - Phone:843-674-1670
Practice Address - Fax:843-674-4707
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINAS MEDICAL ALLIANCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5395208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC053952Medicaid
SC053952Medicaid
SCC60685Medicare UPIN