Basic Information
| Provider Information | |||||||||
| NPI: | 1750487872 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GAINESVILLE UROLOGY CENTER PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4881 NW 8TH AVE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523736338 | ||||||||
| FaxNumber: | 3523736144 | ||||||||
| Practice Location | |||||||||
| Address1: | 4881 NW 8TH AVE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326054582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523736338 | ||||||||
| FaxNumber: | 3523736144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GADDY | ||||||||
| AuthorizedOfficialFirstName: | CLARK | ||||||||
| AuthorizedOfficialMiddleName: | DALE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3523736338 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | ME0048155 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 43583 | 01 | FL | BCBS FL GROUP NUMBER | OTHER |