Provider Demographics
NPI:1831182088
Name:LINCOLN UROLOGY PA
Entity type:Organization
Organization Name:LINCOLN UROLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:B
Authorized Official - Last Name:MIEDEMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-732-4409
Mailing Address - Street 1:206 GAMBLE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:LINCOLNTON
Mailing Address - State:NC
Mailing Address - Zip Code:28092-4439
Mailing Address - Country:US
Mailing Address - Phone:704-732-4409
Mailing Address - Fax:704-735-5784
Practice Address - Street 1:206 GAMBLE DR
Practice Address - Street 2:SUITE C
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-4439
Practice Address - Country:US
Practice Address - Phone:704-732-4409
Practice Address - Fax:704-735-5784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89135MKMedicaid
NC89135MKMedicaid
NCB90433Medicare UPIN
NC2336611Medicare ID - Type Unspecified