Basic Information
| Provider Information | |||||||||
| NPI: | 1649491606 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UROLOGICAL CLINIC OF VALDOSTA PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3294 NORTH OAK ST. EXT. | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292411188 | ||||||||
| FaxNumber: | 2292457106 | ||||||||
| Practice Location | |||||||||
| Address1: | 3294 NORTH OAK ST. EXT. | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292411188 | ||||||||
| FaxNumber: | 2292457106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 07/05/2017 | ||||||||
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| AuthorizedOfficialLastName: | CHIANG | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | SYRU | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 2292411188 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 18627 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | 018627 | GA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 340005901 | 01 | MEDICARE RAILROAD | OTHER | 000244791B | 05 | GA | MEDICAID |