Provider Demographics
NPI:1740367457
Name:UROLOGY ENTERPRISES, PC
Entity type:Organization
Organization Name:UROLOGY ENTERPRISES, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:N PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MBA CMPE CASC
Authorized Official - Phone:770-428-3995
Mailing Address - Street 1:55 WHITCHER ST NE STE 250
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1169
Mailing Address - Country:US
Mailing Address - Phone:770-428-4475
Mailing Address - Fax:
Practice Address - Street 1:55 WHITCHER ST NE STE 250
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1169
Practice Address - Country:US
Practice Address - Phone:770-428-4475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GRP2835Medicare PIN
GACE7282Medicare PIN