Basic Information
Provider Information
NPI: 1467873935
EntityType: 2
ReplacementNPI:  
OrganizationName: WAYNE HEALTH UROLOGICAL ASSOCIATES LLC
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Mailing Information
Address1: PO BOX 1717
Address2:  
City: GOLDSBORO
State: NC
PostalCode: 275331717
CountryCode: US
TelephoneNumber: 9195874081
FaxNumber: 9195870775
Practice Location
Address1: 1112 GRACIE PL
Address2:  
City: GOLDSBORO
State: NC
PostalCode: 275342260
CountryCode: US
TelephoneNumber: 9195874081
FaxNumber: 9195870775
Other Information
ProviderEnumerationDate: 12/30/2013
LastUpdateDate: 12/10/2015
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AuthorizedOfficialLastName: THOMAS
AuthorizedOfficialFirstName: CLYDE
AuthorizedOfficialMiddleName: LOUIS
AuthorizedOfficialTitleorPosition: EXECUTIVE DIRECTOR
AuthorizedOfficialTelephone: 9195874081
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: WAYNE HEALTH PHYSICIANS
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix: II
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Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208800000X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansUrology 

No ID Information.


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