Healthcare Provider Details

I. General information

NPI: 1902982051
Provider Name (Legal Business Name): UROLOGY ASSOCIATES MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 EAST BROADWAY SUITE 207
JACKSON WY
83001-9998
US

IV. Provider business mailing address

PO BOX 12890
JACKSON WY
83002-2890
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-7460
  • Fax: 307-733-7482
Mailing address:
  • Phone: 307-733-7460
  • Fax: 307-733-7482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number6215A
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number6215A
License Number StateWY

VIII. Authorized Official

Name: PHILLIP LOWE
Title or Position: PRESIDENT
Credential: MD
Phone: 307-733-7460