Provider Demographics
NPI:1316065436
Name:SOUTHERN UROLOGY, P. A.
Entity type:Organization
Organization Name:SOUTHERN UROLOGY, P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:T
Authorized Official - Last Name:AZAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-450-2401
Mailing Address - Street 1:139 FAIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1303
Mailing Address - Country:US
Mailing Address - Phone:601-450-2401
Mailing Address - Fax:601-450-2410
Practice Address - Street 1:139 FAIRFIELD DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1303
Practice Address - Country:US
Practice Address - Phone:601-450-2417
Practice Address - Fax:601-450-2410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05137554Medicaid
MSDC4565Medicare PIN
MSC03142Medicare UPIN
MS5272990001Medicare NSC