Basic Information
| Provider Information | |||||||||
| NPI: | 1013981968 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KILLORIN | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | WYLLY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1538 13TH AVENUE | ||||||||
| Address2: | BLD A | ||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063234000 | ||||||||
| FaxNumber: | 7063234848 | ||||||||
| Practice Location | |||||||||
| Address1: | 1538 13TH AVENUE | ||||||||
| Address2: | BLD A | ||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063234000 | ||||||||
| FaxNumber: | 7063234848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 02/25/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 032219 | GA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 005420778 | 05 | GA | MEDICAID |