Provider Demographics
NPI:1780797183
Name:CENTRAL TEXAS UROLOGIC ASSOCIATES, P.A.
Entity type:Organization
Organization Name:CENTRAL TEXAS UROLOGIC ASSOCIATES, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLILAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-741-6113
Mailing Address - Street 1:601 W STATE HIGHWAY 6
Mailing Address - Street 2:105
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-5591
Mailing Address - Country:US
Mailing Address - Phone:254-741-6113
Mailing Address - Fax:254-741-6629
Practice Address - Street 1:601 W STATE HWY 6
Practice Address - Street 2:105
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-5575
Practice Address - Country:US
Practice Address - Phone:254-741-6113
Practice Address - Fax:254-741-6629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00G20LOtherMEDICARE GROUP
TX082657002Medicaid
TX0323870001Medicare NSC