Basic Information
| Provider Information | |||||||||
| NPI: | 1184654873 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UROLOGY INSTITUTE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5126 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053351952 | ||||||||
| FaxNumber: | 6053739971 | ||||||||
| Practice Location | |||||||||
| Address1: | 911 E 20TH ST STE 501 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053228275 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 02/22/2013 | ||||||||
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| AuthorizedOfficialLastName: | O'CONNELL | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 6053228275 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 0423 | SD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 10025081200 | 05 | NE | MEDICAID | 264L4UR | 01 | MN | BCBS - GROUP | OTHER |