Provider Demographics
NPI:1720060841
Name:TULLAHOMA UROLOGY CENTER, P.L.L.C.
Entity Type:Organization
Organization Name:TULLAHOMA UROLOGY CENTER, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:BURSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-454-1955
Mailing Address - Street 1:PO BOX 1718
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-1718
Mailing Address - Country:US
Mailing Address - Phone:931-454-1955
Mailing Address - Fax:931-454-1956
Practice Address - Street 1:107 LEDFORD MILL RD
Practice Address - Street 2:SUITE 210
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-2278
Practice Address - Country:US
Practice Address - Phone:931-454-1955
Practice Address - Fax:931-454-1956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40439208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4116328OtherBCBS/TN
D51838Medicare UPIN
TN3732272Medicare PIN