Provider Demographics
NPI:1780601120
Name:PEDIATRIC UROLOGY OF NORTH CAROLINA
Entity type:Organization
Organization Name:PEDIATRIC UROLOGY OF NORTH CAROLINA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:P
Authorized Official - Last Name:BUKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-785-1888
Mailing Address - Street 1:2406 BLUE RIDGE RD
Mailing Address - Street 2:SUITE 190
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6678
Mailing Address - Country:US
Mailing Address - Phone:919-785-1888
Mailing Address - Fax:
Practice Address - Street 1:2406 BLUE RIDGE RD
Practice Address - Street 2:SUITE 190
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6678
Practice Address - Country:US
Practice Address - Phone:919-785-1888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC95008492088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2212843AMedicare PIN