Basic Information
| Provider Information | |||||||||
| NPI: | 1154430999 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UROLOGY AND ONCOLOGY SPECIALISTS P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3719 DAUPHIN ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366081753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514145665 | ||||||||
| FaxNumber: | 2514145571 | ||||||||
| Practice Location | |||||||||
| Address1: | 3719 DAUPHIN ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366081753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514145665 | ||||||||
| FaxNumber: | 2514145571 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 04/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | ELLINGWOOD | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2514145665 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 04/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 528600100 | 05 | AL | MEDICAID |