Healthcare Provider Details

I. General information

NPI: 1376593061
Provider Name (Legal Business Name): PEDIATRIC UROLOGY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 08/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3135 SPRINGBANK LANE SUITE 200
CHARLOTTE NC
28226-3360
US

IV. Provider business mailing address

3135 SPRINGBANK LANE SUITE 200
CHARLOTTE NC
28226-3360
US

V. Phone/Fax

Practice location:
  • Phone: 704-540-3667
  • Fax: 704-540-3668
Mailing address:
  • Phone: 704-540-3667
  • Fax: 704-540-3668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number9600282
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1000392
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number103556
License Number StateNC

VIII. Authorized Official

Name: DR. JOSEPH A. MOLITIESM JR.
Title or Position: COO
Credential: M.D.
Phone: 407-540-3667