Healthcare Provider Details

I. General information

NPI: 1730845009
Provider Name (Legal Business Name): SCMG - UROLOGIC SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2021
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 COLLIERS WAY STE 509
WEIRTON WV
26062-5054
US

IV. Provider business mailing address

1000 BOWER HILL RD
PITTSBURGH PA
15243-1873
US

V. Phone/Fax

Practice location:
  • Phone: 304-723-4610
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: PAMALYN PATNESKY
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 412-942-2548