Healthcare Provider Details

I. General information

NPI: 1801389267
Provider Name (Legal Business Name): ADVANCED UROLOGIC ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19001 E 48TH ST S
INDEPENDENCE MO
64055-6964
US

IV. Provider business mailing address

901 E 104TH ST
KANSAS CITY MO
64131-4517
US

V. Phone/Fax

Practice location:
  • Phone: 816-502-8782
  • Fax:
Mailing address:
  • Phone: 816-502-8782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KAREN RAWERT
Title or Position: MANAGER, PAYOR ENROLLMENT
Credential:
Phone: 816-502-8782