Provider Demographics
NPI:1730621624
Name:UROLOGY GROUP PC
Entity type:Organization
Organization Name:UROLOGY GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-767-8158
Mailing Address - Street 1:6029 WALNUT GROVE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2112
Mailing Address - Country:US
Mailing Address - Phone:901-767-8158
Mailing Address - Fax:901-328-5853
Practice Address - Street 1:302 S RHODES ST
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4215
Practice Address - Country:US
Practice Address - Phone:901-767-8158
Practice Address - Fax:901-328-5853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-09
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
291U00000X
TN26045208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNG00869Medicare UPIN