Basic Information
| Provider Information | |||||||||
| NPI: | 1164407151 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOBILE UROLOGY GROUP, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 MEMORIAL HOSPITAL DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366081786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513439090 | ||||||||
| FaxNumber: | 2513801015 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 MEMORIAL HOSPITAL DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366081786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513439090 | ||||||||
| FaxNumber: | 2513801015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2005 | ||||||||
| LastUpdateDate: | 01/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | FLECK | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2513439090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0635230001 | 01 | AL | DMERC JURISDICTION C | OTHER |