Basic Information
| Provider Information | |||||||||
| NPI: | 1790705572 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UROLOGY ASSOC OF PORT HURON, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1037 WATER ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480604408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109844194 | ||||||||
| FaxNumber: | 8109844674 | ||||||||
| Practice Location | |||||||||
| Address1: | 1037 WATER ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480604408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109844194 | ||||||||
| FaxNumber: | 8109844674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 01/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | ADAIR | ||||||||
| AuthorizedOfficialFirstName: | DORIS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8109844194 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 540G41006 | 01 | MI | BLUE CROSS | OTHER | 0G41055 | 01 | MI | BLUE CROSS GROUP ID | OTHER |