Basic Information
| Provider Information | |||||||||
| NPI: | 1023091691 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SALISBURY UROLOGICAL CLINIC, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 911 W HENDERSON ST | ||||||||
| Address2: | STE 110 | ||||||||
| City: | SALISBURY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281442736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046339441 | ||||||||
| FaxNumber: | 7046379006 | ||||||||
| Practice Location | |||||||||
| Address1: | 911 W HENDERSON ST | ||||||||
| Address2: | STE 110 | ||||||||
| City: | SALISBURY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281442736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046339441 | ||||||||
| FaxNumber: | 7046379006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CLINE | ||||||||
| AuthorizedOfficialFirstName: | WAYNE | ||||||||
| AuthorizedOfficialMiddleName: | ALLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7046339441 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 8902595 | 05 | NC | MEDICAID |