Basic Information
| Provider Information | |||||||||
| NPI: | 1366067233 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. LUKE'S PHYSICIAN NETWORK INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. LUKE'S UROLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19305 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282199305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046310002 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 54 HOSPITAL DR | ||||||||
| Address2: | STE 3B | ||||||||
| City: | COLUMBUS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287228516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288943230 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2020 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
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| AuthorizedOfficialLastName: | PRESNELL | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8288940954 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. LUKE'S PHYSICIAN NETWORK INC. | ||||||||
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| NPICertificationDate: | 06/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.