Basic Information
Provider Information | |||||||||
NPI: | 1073896510 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADVANCED UROLOGY INSTITUTE OF GEORGIA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 628231 MAIL CODE: 5068 | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328628231 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6783448900 | ||||||||
FaxNumber: | 6786665201 | ||||||||
Practice Location | |||||||||
Address1: | 1557 JANMAR RD | ||||||||
Address2: |   | ||||||||
City: | SNELLVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 300785686 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6783448900 | ||||||||
FaxNumber: | 6786665201 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/21/2011 | ||||||||
LastUpdateDate: | 09/12/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PATEL | ||||||||
AuthorizedOfficialFirstName: | JITESH | ||||||||
AuthorizedOfficialMiddleName: | VINOD | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
AuthorizedOfficialTelephone: | 6783448900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: | 05/21/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 65869 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |   |
No ID Information.