Basic Information
| Provider Information | |||||||||
| NPI: | 1396836359 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHWOODS UROLOGY ASSOCIATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHWOODS UROLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4959 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814043000 | ||||||||
| FaxNumber: | 9362735628 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 VISION PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | SHENANDOAH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773843001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814043000 | ||||||||
| FaxNumber: | 9362735628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 07/18/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KENWORTHY | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | M.D. | ||||||||
| AuthorizedOfficialTelephone: | 2814043000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 083481402 | 05 | TX | MEDICAID |