Provider Demographics
NPI:1942472675
Name:TRI-LAKES UROLOGY, INC
Entity Type:Organization
Organization Name:TRI-LAKES UROLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:GIVENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-335-7736
Mailing Address - Street 1:PO BOX 751
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73101-0751
Mailing Address - Country:US
Mailing Address - Phone:405-858-2350
Mailing Address - Fax:405-858-2365
Practice Address - Street 1:545 BRANSON LANDING BLVD
Practice Address - Street 2:SUITE 307
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-4500
Practice Address - Country:US
Practice Address - Phone:417-335-7736
Practice Address - Fax:417-334-3038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR9B09208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1089490001OtherRAILROAD MEDICARE
MO14360OtherBLUE SHIELD
AR152379001Medicaid
MO202355806Medicaid
AR152379001Medicaid
MO202355806Medicaid