Provider Demographics
NPI:1861572968
Name:UROLOGY TYLER, PA
Entity type:Organization
Organization Name:UROLOGY TYLER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STANTON
Authorized Official - Middle Name:P
Authorized Official - Last Name:CHAMPION
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-262-3900
Mailing Address - Street 1:PO BOX 8026
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-8026
Mailing Address - Country:US
Mailing Address - Phone:903-262-3900
Mailing Address - Fax:903-262-3993
Practice Address - Street 1:700 OLYMPIC PLAZA CIR STE 700
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1954
Practice Address - Country:US
Practice Address - Phone:903-262-3900
Practice Address - Fax:903-262-3993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112852203Medicaid
TXCR0481Medicare PIN
TX00L23VMedicare PIN