Provider Demographics
NPI:1538229661
Name:UROLOGY SPECIALTIES OF NWA
Entity type:Organization
Organization Name:UROLOGY SPECIALTIES OF NWA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-521-8980
Mailing Address - Street 1:5401 WILLOW CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-8703
Mailing Address - Country:US
Mailing Address - Phone:479-521-8980
Mailing Address - Fax:479-521-1088
Practice Address - Street 1:5401 WILLOW CREEK DR
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-8703
Practice Address - Country:US
Practice Address - Phone:479-521-8980
Practice Address - Fax:479-521-1088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR=========OtherFED TIN
AR5F761Medicare PIN