Basic Information
| Provider Information | |||||||||
| NPI: | 1366474835 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATLANTIC UROLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 600085 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276756085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103628765 | ||||||||
| FaxNumber: | 9103629123 | ||||||||
| Practice Location | |||||||||
| Address1: | 1606 PHYSICIANS DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103628765 | ||||||||
| FaxNumber: | 9103629123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 09/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | MYNATT | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9103628765 | ||||||||
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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 | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 89011MU | 05 | NC | MEDICAID |