Provider Demographics
NPI:1649487083
Name:UROLOGIC SURGICAL ASSOCIATES
Entity type:Organization
Organization Name:UROLOGIC SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:LIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-925-8521
Mailing Address - Street 1:11 COURTNEY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-2699
Mailing Address - Country:US
Mailing Address - Phone:304-925-8521
Mailing Address - Fax:304-925-8523
Practice Address - Street 1:11 COURTNEY DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2699
Practice Address - Country:US
Practice Address - Phone:304-925-8521
Practice Address - Fax:304-925-8523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9293611Medicare PIN