Basic Information
| Provider Information | |||||||||
| NPI: | 1184626350 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PIEDMONT UROLOGY ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 924 COX RD | ||||||||
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| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280543456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048690075 | ||||||||
| FaxNumber: | 7048698875 | ||||||||
| Practice Location | |||||||||
| Address1: | 924 COX RD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280543456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048690075 | ||||||||
| FaxNumber: | 7048698875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 04/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | WATERHOUSE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7048690075 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 0099-01352 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 02266 | 01 | NC | BCBS OF NC PROVIDER NUMBE | OTHER | 8902266 | 05 | NC | MEDICAID |