Provider Demographics
NPI:1396779039
Name:UNIVERSITY PEDIATRIC UROLOGY, PC
Entity type:Organization
Organization Name:UNIVERSITY PEDIATRIC UROLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-637-7290
Mailing Address - Street 1:2100 W CLINCH AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-2288
Mailing Address - Country:US
Mailing Address - Phone:865-637-7290
Mailing Address - Fax:865-637-7289
Practice Address - Street 1:2100 W CLINCH AVE STE 120
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-2288
Practice Address - Country:US
Practice Address - Phone:865-637-7290
Practice Address - Fax:865-637-7289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3379815Medicare ID - Type Unspecified