Provider Demographics
NPI:1942282256
Name:UROLOGY SPECIALTY AND SURGERY CENTER OF SOUTHWEST LOUISIANA
Entity Type:Organization
Organization Name:UROLOGY SPECIALTY AND SURGERY CENTER OF SOUTHWEST LOUISIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:S
Authorized Official - Last Name:VERHEECK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:337-439-8857
Mailing Address - Street 1:234 DR MICHAEL DEBAKEY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5960
Mailing Address - Country:US
Mailing Address - Phone:337-439-8857
Mailing Address - Fax:337-433-1159
Practice Address - Street 1:234 DR MICHAEL DEBAKEY DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-5960
Practice Address - Country:US
Practice Address - Phone:337-439-8857
Practice Address - Fax:337-433-1159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-14
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA42261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA490001185OtherRAILROAD MEDICARE
LA1390429Medicaid
LA2097COtherBLUE CROSS BLUE SHIELD
LA490001185OtherRAILROAD MEDICARE
LA=========0000OtherTRICARE
LA11034Medicare ID - Type Unspecified