Basic Information
| Provider Information | |||||||||
| NPI: | 1447395066 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAROLINA UROLOGY PRACTICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 HOSPITAL DR W | ||||||||
| Address2: | |||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291693405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037968515 | ||||||||
| FaxNumber: | 8037968516 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 HOSPITAL DR W | ||||||||
| Address2: | |||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291693405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037968515 | ||||||||
| FaxNumber: | 8037968516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 05/20/2009 | ||||||||
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| AuthorizedOfficialLastName: | SWEAZY | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8037968515 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAROLINA UROLOGY PRACTICE | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | GP2142 | 05 | SC | MEDICAID |