Provider Demographics
NPI:1821292988
Name:SOUTHEAST ARIZONA UROLOGY CARE
Entity Type:Organization
Organization Name:SOUTHEAST ARIZONA UROLOGY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-803-7640
Mailing Address - Street 1:3533 CANYON DE FLORES STE A
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85650-5366
Mailing Address - Country:US
Mailing Address - Phone:520-803-7640
Mailing Address - Fax:520-803-7886
Practice Address - Street 1:3533 CANYON DE FLORES STE A
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85650-5366
Practice Address - Country:US
Practice Address - Phone:520-803-7640
Practice Address - Fax:520-803-7886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27092208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ77310Medicare PIN