Provider Demographics
NPI:1427252253
Name:SHOALS UROLOGICAL ASSOCIATES PC
Entity type:Organization
Organization Name:SHOALS UROLOGICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LONGMIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-381-2628
Mailing Address - Street 1:1015 S JACKSON HWY
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD
Mailing Address - State:AL
Mailing Address - Zip Code:35660-5760
Mailing Address - Country:US
Mailing Address - Phone:256-381-2628
Mailing Address - Fax:256-386-5551
Practice Address - Street 1:607 GANDY ST NE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-1911
Practice Address - Country:US
Practice Address - Phone:256-381-2628
Practice Address - Fax:256-386-5551
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHOALS UROLOGICAL ASSOCIATES PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-14
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALH504Medicare PIN