Provider Demographics
NPI:1396766259
Name:GRIFFIN UROLOGY, PC
Entity type:Organization
Organization Name:GRIFFIN UROLOGY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LUCIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:TATUM
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:770-227-1075
Mailing Address - Street 1:653 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4242
Mailing Address - Country:US
Mailing Address - Phone:770-227-1075
Mailing Address - Fax:770-227-1085
Practice Address - Street 1:653 S 8TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4242
Practice Address - Country:US
Practice Address - Phone:770-227-1075
Practice Address - Fax:770-227-1085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA009748174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00111229CMedicaid
GA00111229CMedicaid
GAGRP7816Medicare PIN