Provider Demographics
NPI:1154589901
Name:UROLOGY GROUP, PC
Entity type:Organization
Organization Name:UROLOGY GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:A
Authorized Official - Last Name:EDDLESTONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-271-2272
Mailing Address - Street 1:907 E REED ST
Mailing Address - Street 2:
Mailing Address - City:HAYTI
Mailing Address - State:MO
Mailing Address - Zip Code:63851-1242
Mailing Address - Country:US
Mailing Address - Phone:901-767-8158
Mailing Address - Fax:
Practice Address - Street 1:907 E REED ST
Practice Address - Street 2:
Practice Address - City:HAYTI
Practice Address - State:MO
Practice Address - Zip Code:63851-1242
Practice Address - Country:US
Practice Address - Phone:901-767-8158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO119325208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000015398OtherMO MEDICARE GROUP NUMBER