Healthcare Provider Details

I. General information

NPI: 1730621624
Provider Name (Legal Business Name): UROLOGY GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 S RHODES ST
WEST MEMPHIS AR
72301-4215
US

IV. Provider business mailing address

6029 WALNUT GROVE RD SUITE 300
MEMPHIS TN
38120-2112
US

V. Phone/Fax

Practice location:
  • Phone: 901-767-8158
  • Fax: 901-328-5853
Mailing address:
  • Phone: 901-767-8158
  • Fax: 901-328-5853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number26045
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: ANGIE WILSON
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 901-767-8158