Basic Information
| Provider Information | |||||||||
| NPI: | 1811364144 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED UROLOGY OF THE PEE DEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100523 | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295020523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436695162 | ||||||||
| FaxNumber: | 8436674573 | ||||||||
| Practice Location | |||||||||
| Address1: | 309 W PINE ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295014726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436188609 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2015 | ||||||||
| LastUpdateDate: | 02/23/2016 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8436188609 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | SC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | DW2056 | 01 | SC | RAILROAD MEDICARE | OTHER | GP6980 | 05 | SC | MEDICAID |