Provider Demographics
NPI:1922181494
Name:MONTGOMERY UROLOGY CLINIC
Entity Type:Organization
Organization Name:MONTGOMERY UROLOGY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DALJIT
Authorized Official - Middle Name:S
Authorized Official - Last Name:CABERWAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-572-3410
Mailing Address - Street 1:1001 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NC
Mailing Address - Zip Code:27371
Mailing Address - Country:US
Mailing Address - Phone:910-572-3900
Mailing Address - Fax:
Practice Address - Street 1:1001 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NC
Practice Address - Zip Code:27371
Practice Address - Country:US
Practice Address - Phone:910-572-3900
Practice Address - Fax:910-572-3410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2011-12-08
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-08-08
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC01064OtherBCBS
NC7901064Medicaid
NC7901064Medicaid