Provider Demographics
NPI:1023078649
Name:UPPER CUMBERLAND UROLOGY ASSOCIATES PC
Entity type:Organization
Organization Name:UPPER CUMBERLAND UROLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:V
Authorized Official - Last Name:GORYL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-528-5547
Mailing Address - Street 1:320 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2440
Mailing Address - Country:US
Mailing Address - Phone:931-528-5547
Mailing Address - Fax:931-526-2699
Practice Address - Street 1:320 N OAK AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2440
Practice Address - Country:US
Practice Address - Phone:931-528-5547
Practice Address - Fax:931-526-2699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2008612OtherBLUE CROSS BLUE SHIELD
TN3378641Medicaid
TN3378641Medicaid