Provider Demographics
NPI:1104922749
Name:UROLOGY ASSOCIATES OF SOUTHERN OREGON, LLP
Entity type:Organization
Organization Name:UROLOGY ASSOCIATES OF SOUTHERN OREGON, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:FADLING
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:541-772-6600
Mailing Address - Street 1:2900 DOCTORS PARK DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6111
Mailing Address - Country:US
Mailing Address - Phone:541-772-6600
Mailing Address - Fax:541-779-1266
Practice Address - Street 1:2900 DOCTORS PARK DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8198
Practice Address - Country:US
Practice Address - Phone:541-772-6600
Practice Address - Fax:541-779-1266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR001930000OtherBLUE CROSS BLUE SHIELD ID
OR292844Medicaid
OR001930000OtherBLUE CROSS BLUE SHIELD ID