Healthcare Provider Details

I. General information

NPI: 1790055473
Provider Name (Legal Business Name): UROLOGY NEVADA LTD DRS DREW FREEMAN GAREY-SAGE GOODE HALD KANELLOS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5560 KIETZKE LN BLDG. A
RENO NV
89511
US

IV. Provider business mailing address

5560 KIETZKE LN BLDG. A
RENO NV
89511
US

V. Phone/Fax

Practice location:
  • Phone: 775-322-7811
  • Fax: 775-322-1431
Mailing address:
  • Phone: 775-322-7811
  • Fax: 775-322-1431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberNV20071378617
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberNV20071378617
License Number StateNV

VIII. Authorized Official

Name: STEPHEN GABELICH
Title or Position: CHIEF OPERATING OFFICER
Credential: FACMPE
Phone: 775-322-7811