Basic Information
| Provider Information | |||||||||
| NPI: | 1306935341 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UROLOGY GROUP OF PADUCAH, P.S.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2603 KENTUCKY AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420033814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704423539 | ||||||||
| FaxNumber: | 2704422051 | ||||||||
| Practice Location | |||||||||
| Address1: | 2603 KENTUCKY AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420033818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704423539 | ||||||||
| FaxNumber: | 2704422051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 12/04/2007 | ||||||||
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| AuthorizedOfficialLastName: | SPICER | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2704423539 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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 | 0152170001 | 01 | KY | MEDICARE DMERC | OTHER |