Basic Information
| Provider Information | |||||||||
| NPI: | 1104183953 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FIRST UROLOGY, PSC | ||||||||
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| OtherOrganizationName: | SOUTHERN INDIANA RADIATION THERAPY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 HOSPITAL BLVD | ||||||||
| Address2: | |||||||||
| City: | JEFFERSONVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471303769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122823899 | ||||||||
| FaxNumber: | 8122824172 | ||||||||
| Practice Location | |||||||||
| Address1: | 3920 S DUPONT SQ | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5027210116 | ||||||||
| FaxNumber: | 8122824172 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2012 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | SHANNON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8122823899 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FIRST UROLOGY, PSC | ||||||||
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| NPICertificationDate: | 05/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 363L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 208800000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 65906414 | 05 | KY | MEDICAID | 78902830 | 05 | KY | MEDICAID |