Provider Demographics
NPI:1992762728
Name:WILSON UROLOGY PA
Entity type:Organization
Organization Name:WILSON UROLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:ROUNDER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:252-243-5511
Mailing Address - Street 1:PO BOX 3329
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27895
Mailing Address - Country:US
Mailing Address - Phone:252-243-5511
Mailing Address - Fax:252-399-7575
Practice Address - Street 1:2509 WOOTEN BLVD SW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27895
Practice Address - Country:US
Practice Address - Phone:252-243-5511
Practice Address - Fax:252-399-7575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890213FMedicaid
NC2318011Medicare ID - Type UnspecifiedGROUP