Healthcare Provider Details

I. General information

NPI: 1851989669
Provider Name (Legal Business Name): ASSOCIATED UROLOGISTS OF NORTH CAROLINA, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 AVENT FERRY RD STE 204
HOLLY SPRINGS NC
27540-7776
US

IV. Provider business mailing address

105 SW CARY PKWY STE 105
CARY NC
27511-5600
US

V. Phone/Fax

Practice location:
  • Phone: 919-467-3203
  • Fax: 919-460-8915
Mailing address:
  • Phone: 919-863-9441
  • Fax: 919-863-9442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KISSIAH BURVIG
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 919-863-9441