Basic Information
| Provider Information | |||||||||
| NPI: | 1396918983 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRANSYLVANIA PHYSICIAN SERVICES, INC. | ||||||||
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| OtherOrganizationName: | PISGAH UROLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602373 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282131500 | ||||||||
| FaxNumber: | 8286516570 | ||||||||
| Practice Location | |||||||||
| Address1: | 87 MEDICAL PARK DR STE A | ||||||||
| Address2: | |||||||||
| City: | BREVARD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287123210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288835858 | ||||||||
| FaxNumber: | 8288843339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2008 | ||||||||
| LastUpdateDate: | 04/28/2018 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | RHONDA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF REVENUE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8286514144 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRANSYLVANIA PHYSICIAN SERVICES, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2088F0040X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | Female Pelvic Medicine and Reconstructive Surgery | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 208800000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 1196190 | 01 | NC | GATEWAY HEALTH PLAN | OTHER | 2966714 | 01 | NC | UNITED HEALTHCARE | OTHER |