Provider Demographics
NPI:1356514129
Name:UROLOGY CLINIC OF TANGIPAHOA
Entity type:Organization
Organization Name:UROLOGY CLINIC OF TANGIPAHOA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:V
Authorized Official - Last Name:KIDD
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:985-542-7766
Mailing Address - Street 1:2101 ROBIN AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-5772
Mailing Address - Country:US
Mailing Address - Phone:985-542-7766
Mailing Address - Fax:985-542-1754
Practice Address - Street 1:2101 ROBIN AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-5772
Practice Address - Country:US
Practice Address - Phone:985-542-7766
Practice Address - Fax:985-542-1754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAC50367Medicare PIN
LA5B858Medicare PIN