Provider Demographics
NPI:1780615401
Name:SCOTTSBLUFF UROLOGY ASSOC PC
Entity type:Organization
Organization Name:SCOTTSBLUFF UROLOGY ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:N
Authorized Official - Last Name:KABALIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:308-632-5315
Mailing Address - Street 1:3911 AVENUE B
Mailing Address - Street 2:2200
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4617
Mailing Address - Country:US
Mailing Address - Phone:308-632-5315
Mailing Address - Fax:308-632-5261
Practice Address - Street 1:3911 AVENUE B
Practice Address - Street 2:2200
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4617
Practice Address - Country:US
Practice Address - Phone:308-632-5315
Practice Address - Fax:308-632-5261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY102713100Medicaid
NE=========13Medicaid
NE095608Medicare ID - Type Unspecified