Provider Demographics
NPI:1902982051
Name:UROLOGY ASSOCIATES MEDICAL GROUP, PC
Entity Type:Organization
Organization Name:UROLOGY ASSOCIATES MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:LOWE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-733-7460
Mailing Address - Street 1:PO BOX 12890
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83002-2890
Mailing Address - Country:US
Mailing Address - Phone:307-733-7460
Mailing Address - Fax:307-733-7482
Practice Address - Street 1:555 EAST BROADWAY
Practice Address - Street 2:SUITE 207
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-9998
Practice Address - Country:US
Practice Address - Phone:307-733-7460
Practice Address - Fax:307-733-7482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6215A208800000X, 2088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY114954700Medicaid
ID806684400Medicaid
WY118827500Medicaid
ID806233600Medicaid
ID806684400Medicaid
WYW9787Medicare PIN
WY114954700Medicaid
ID806684400Medicaid
ID1376898Medicare ID - Type UnspecifiedID MEDICARE GROUP#