Provider Demographics
NPI:1588765481
Name:UROLOGY CLINIC OF JACKSONVILLE NC INC
Entity type:Organization
Organization Name:UROLOGY CLINIC OF JACKSONVILLE NC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:UROLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BOOKER
Authorized Official - Middle Name:T
Authorized Official - Last Name:KEYES
Authorized Official - Suffix:JR
Authorized Official - Credentials:M D
Authorized Official - Phone:910-355-0900
Mailing Address - Street 1:260 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6332
Mailing Address - Country:US
Mailing Address - Phone:910-355-0900
Mailing Address - Fax:910-355-1940
Practice Address - Street 1:260 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6332
Practice Address - Country:US
Practice Address - Phone:910-355-0900
Practice Address - Fax:910-355-1940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32127174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC82353Medicare UPIN