MEDICARE: METROLINA UROLOGY CLINIC PA

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	208800000X	Urology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0124P	OTHER		BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1952380958
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	METROLINA UROLOGY CLINIC PA

Provider Business Mailing Address
First Line	:	1900 RANDOLPH RD
Second Line	:	SUITE 310
City	:	CHARLOTTE
State	:	NC
Zip	:	28207-1106
Country	:	US
Telephone Number	:	704-358-8780
Fax Number	:	704-358-1530

Provider Business Practice Location Address
First Line	:	1900 RANDOLPH RD
Second Line	:	SUITE 310
City	:	CHARLOTTE
State	:	NC
Zip	:	28207-1106
Country	:	US
Telephone Number	:	704-358-8780
Fax Number	:	704-358-1530

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DEREK C GARDNER
Credential	:	MD
Telephone Number	:	704-358-8780

Provider Enumeration Date	:	01/10/2006
Last Update Date	:	08/22/2020

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Practice Location Address:

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Directions to “METROLINA UROLOGY CLINIC PA ” Practice Location

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