Healthcare Provider Details

I. General information

NPI: 1104877141
Provider Name (Legal Business Name): UNIVERSITY UROLOGISTS, INC., PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 BARNHILL DR STE 420
INDIANAPOLIS IN
46202-5116
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-278-1979
  • Fax: 317-278-1981
Mailing address:
  • Phone: 888-484-3258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01048495A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number01048495A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number71001248A
License Number StateIN

VIII. Authorized Official

Name: DR. MICHAEL O KOCH
Title or Position: PRESIDENT
Credential: MD
Phone: 317-944-7338