Provider Demographics
NPI:1861695579
Name:MOULTRIE UROLOGICAL CLINIC, INC
Entity type:Organization
Organization Name:MOULTRIE UROLOGICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAHA
Authorized Official - Middle Name:KASSIS
Authorized Official - Last Name:BADDOUR
Authorized Official - Suffix:
Authorized Official - Credentials:RMM, MBA
Authorized Official - Phone:229-985-3066
Mailing Address - Street 1:2 HOSPITAL PARK
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-6700
Mailing Address - Country:US
Mailing Address - Phone:229-985-3066
Mailing Address - Fax:229-890-2092
Practice Address - Street 1:2 HOSPITAL PARK
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6700
Practice Address - Country:US
Practice Address - Phone:229-985-3066
Practice Address - Fax:229-890-2092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031557174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00400518AMedicaid
GAGRP4674Medicare PIN