Basic Information
| Provider Information | |||||||||
| NPI: | 1457851255 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED UROLOGY INSTITUTE OF GEORGIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 628231 MAIL CODE: 5068 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328628231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783448900 | ||||||||
| FaxNumber: | 4044927021 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 CROWN POINT WAY | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783448900 | ||||||||
| FaxNumber: | 6786665201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2018 | ||||||||
| LastUpdateDate: | 09/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | BENNETT | ||||||||
| AuthorizedOfficialFirstName: | CAROL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7064614604 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVANCED UROLOGY INSTITUTE OF GEORGIA | ||||||||
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| NPICertificationDate: | 09/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.