MEDICARE: UROLOGY CLINIC OF SOUTH ALABAMA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	AL00025839	AL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DG3879	OTHER		RAILROAD MEDICARE

General Provider Information

NPI Number	:	1013100627
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UROLOGY CLINIC OF SOUTH ALABAMA, LLC

Provider Business Mailing Address
First Line	:	215 MEDICAL PARK DR
Second Line	:	SUITE 2
City	:	ANDALUSIA
State	:	AL
Zip	:	36420-5311
Country	:	US
Telephone Number	:	334-427-7218
Fax Number	:	334-427-4999

Provider Business Practice Location Address
First Line	:	215 MEDICAL PARK DR
Second Line	:	SUITE 2
City	:	ANDALUSIA
State	:	AL
Zip	:	36420-5311
Country	:	US
Telephone Number	:	334-427-7218
Fax Number	:	334-427-4999

Authorized Official
Title or Position	:	OWNER
Name	:	ALEXANDRU E BENET
Credential	:	MD
Telephone Number	:	334-427-7218

Provider Enumeration Date	:	08/27/2007
Last Update Date	:	02/14/2008

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