Basic Information
| Provider Information | |||||||||
| NPI: | 1861782864 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VIRTUAL URODYNAMICS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2340 KATY LN | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639012300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737767393 | ||||||||
| FaxNumber: | 5737767396 | ||||||||
| Practice Location | |||||||||
| Address1: | 2340 KATY LN | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639012300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737767393 | ||||||||
| FaxNumber: | 5737767396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2011 | ||||||||
| LastUpdateDate: | 04/11/2011 | ||||||||
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| AuthorizedOfficialLastName: | CARDA | ||||||||
| AuthorizedOfficialFirstName: | CARRIE | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5737767393 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | MD111753 | MO | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208800000X | MD111753 | MO | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | 261QM2500X | MD111753 | MO | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.