Basic Information
| Provider Information | |||||||||
| NPI: | 1366547580 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH FULTON UROLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1357 HEMBREE RD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300765722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704757550 | ||||||||
| FaxNumber: | 7703439080 | ||||||||
| Practice Location | |||||||||
| Address1: | 1357 HEMBREE ROAD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704757550 | ||||||||
| FaxNumber: | 7703439080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 04/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | BRUNI | ||||||||
| AuthorizedOfficialFirstName: | JUDY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7704757550 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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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 | CL8520 | 01 | GA | RRMCARE | OTHER |