Provider Demographics
NPI:1194734582
Name:CAPE GIRARDEAU UROLOGY ASSOCIATES, INC.
Entity type:Organization
Organization Name:CAPE GIRARDEAU UROLOGY ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:NUSSBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-334-7748
Mailing Address - Street 1:3 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4927
Mailing Address - Country:US
Mailing Address - Phone:573-334-7748
Mailing Address - Fax:573-334-5724
Practice Address - Street 1:3 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4927
Practice Address - Country:US
Practice Address - Phone:573-334-7748
Practice Address - Fax:573-334-5724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
628OtherBLUE CROSS BLUE SHIELD
MO500616602Medicaid
CP7010OtherRAILROAD MEDICARE
107662OtherHEALTHLINK
MO0296520001Medicare NSC
107662OtherHEALTHLINK