Provider Demographics
NPI:1265437743
Name:REGIONAL UROLOGY ASC LLC
Entity type:Organization
Organization Name:REGIONAL UROLOGY ASC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-683-0411
Mailing Address - Street 1:255 BERT KOUNS LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-8150
Mailing Address - Country:US
Mailing Address - Phone:318-683-0411
Mailing Address - Fax:
Practice Address - Street 1:255 BERT KOUNS LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-8150
Practice Address - Country:US
Practice Address - Phone:318-683-0411
Practice Address - Fax:318-603-5461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA100261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1180793Medicaid
490004967OtherRAILROAD MEDICARE
LA20117OtherBLUE CROSS OF LA
LA20117OtherBLUE CROSS OF LA