Healthcare Provider Details

I. General information

NPI: 1780601120
Provider Name (Legal Business Name): PEDIATRIC UROLOGY OF NORTH CAROLINA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 02/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2406 BLUE RIDGE RD SUITE 190
RALEIGH NC
27607-6678
US

IV. Provider business mailing address

2406 BLUE RIDGE RD SUITE 190
RALEIGH NC
27607-6678
US

V. Phone/Fax

Practice location:
  • Phone: 919-785-1888
  • Fax:
Mailing address:
  • Phone: 919-785-1888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number9500849
License Number StateNC

VIII. Authorized Official

Name: DR. TIMOTHY P BUKOWSKI
Title or Position: PRESIDENT
Credential: MD
Phone: 919-785-1888