Provider Demographics
NPI:1588955744
Name:SMOKY MOUNTAIN UROLOGY, INC
Entity type:Organization
Organization Name:SMOKY MOUNTAIN UROLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSTAN
Authorized Official - Middle Name:JOEL
Authorized Official - Last Name:VAN WYK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:828-698-0896
Mailing Address - Street 1:1334 ASHEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28791-3414
Mailing Address - Country:US
Mailing Address - Phone:828-698-0896
Mailing Address - Fax:828-698-9532
Practice Address - Street 1:1334 ASHEVILLE HWY
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28791-3414
Practice Address - Country:US
Practice Address - Phone:828-698-0896
Practice Address - Fax:828-698-9532
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SMOKY MOUNTAIN UROLOGY, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCBV7069330332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89128F6Medicaid
NC89128F6Medicaid