Basic Information
Provider Information | |||||||||
NPI: | 1952561623 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CAROLINA UROLOGY CENTER, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1780 MEDICAL PARK DR | ||||||||
Address2: |   | ||||||||
City: | ROCK HILL | ||||||||
State: | SC | ||||||||
PostalCode: | 297321194 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8033271116 | ||||||||
FaxNumber: | 8033276872 | ||||||||
Practice Location | |||||||||
Address1: | 580 KINGSLEY PARK DR | ||||||||
Address2: | SUITE 150 | ||||||||
City: | FORT MILL | ||||||||
State: | SC | ||||||||
PostalCode: | 297156403 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8035787600 | ||||||||
FaxNumber: | 8034312257 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2008 | ||||||||
LastUpdateDate: | 12/02/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BLACK | ||||||||
AuthorizedOfficialFirstName: | TRACY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 8033271116 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | PA4307 | 05 | SC |   | MEDICAID |