Provider Demographics
NPI:1962557157
Name:SOUTHERN UROLOGY ASSOCIATES LLC
Entity type:Organization
Organization Name:SOUTHERN UROLOGY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:LAGEESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-988-7044
Mailing Address - Street 1:12330 ASHLEY DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2737
Mailing Address - Country:US
Mailing Address - Phone:228-831-1572
Mailing Address - Fax:228-831-1218
Practice Address - Street 1:12330 ASHLEY DR
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2737
Practice Address - Country:US
Practice Address - Phone:228-831-1572
Practice Address - Fax:228-831-1218
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS=========OtherTAX ID