Provider Demographics
NPI:1649491606
Name:UROLOGICAL CLINIC OF VALDOSTA PC
Entity type:Organization
Organization Name:UROLOGICAL CLINIC OF VALDOSTA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:SYRU
Authorized Official - Last Name:CHIANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-241-1188
Mailing Address - Street 1:3294 NORTH OAK ST. EXT.
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605
Mailing Address - Country:US
Mailing Address - Phone:229-241-1188
Mailing Address - Fax:229-245-7106
Practice Address - Street 1:3294 NORTH OAK ST. EXT.
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605
Practice Address - Country:US
Practice Address - Phone:229-241-1188
Practice Address - Fax:229-245-7106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA18627174400000X
GA018627174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
340005901OtherMEDICARE RAILROAD
GA000244791BMedicaid
D39589Medicare UPIN
34BDBNBMedicare PIN