Provider Demographics
NPI:1720172489
Name:TENNESSEE UROLOGY ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:TENNESSEE UROLOGY ASSOCIATES, PLLC
Other - Org Name:TENNESSEE UROLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAUTERBACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-738-2889
Mailing Address - Street 1:25 CROSSROADS DR STE 306
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5437
Mailing Address - Country:US
Mailing Address - Phone:866-953-3111
Mailing Address - Fax:443-471-8540
Practice Address - Street 1:9245 PARK WEST BLVD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4425
Practice Address - Country:US
Practice Address - Phone:865-276-2764
Practice Address - Fax:865-694-7621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3376991Medicaid
CB1023Medicare PIN
TN3376991Medicare ID - Type Unspecified
TN0347510001Medicare NSC