=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023678000
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE UROLOGY CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2019
-----------------------------------------------------
Last Update Date | 06/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14231 SEAWAY RD STE 6000
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39503-4628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-254-1103
-----------------------------------------------------
Fax | 228-206-2324
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14231 SEAWAY RD STE 6000
-----------------------------------------------------
City | GULFPORT
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39503-4628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-254-1103
-----------------------------------------------------
Fax | 228-206-2324
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD/SOLE MEMBER
-----------------------------------------------------
Name | DR. PAIGE C WHITE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 228-254-1103
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------