Healthcare Provider Details

I. General information

NPI: 1154867562
Provider Name (Legal Business Name): UROLOGIC AMBULATORY SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

499 GLOSTER CREEK VLG STE B8
TUPELO MS
38801-4633
US

IV. Provider business mailing address

PO BOX 829
TUPELO MS
38802-0829
US

V. Phone/Fax

Practice location:
  • Phone: 662-432-0700
  • Fax: 662-846-0566
Mailing address:
  • Phone: 662-377-7100
  • Fax: 662-377-5736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEONNE HENRY
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 662-432-0700