Provider Demographics
NPI:1104877141
Name:UNIVERSITY UROLOGISTS, INC., PC
Entity type:Organization
Organization Name:UNIVERSITY UROLOGISTS, INC., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:O
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-944-7338
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:888-484-3258
Mailing Address - Fax:
Practice Address - Street 1:535 BARNHILL DR STE 420
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5116
Practice Address - Country:US
Practice Address - Phone:317-278-1979
Practice Address - Fax:317-278-1981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048495A2088P0231X, 208800000X
IN71001248A363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
No2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100057570Medicaid
IN100057570Medicaid
INCD4826Medicare PIN