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General NPI Number Information
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NPI Number | 1063627834
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Entity Type | Organization
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Legal Business Name | SMOKY MOUNTAIN UROLOGICAL INC.
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Dates
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Enumeration Date | 05/14/2007
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Last Update Date | 09/26/2011
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Provider Practice Location Address
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Address Line | 1334 ASHEVILLE HWY
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City | HENDERSONVILLE
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State | NC
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Zip | 28791-3414
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Country | US
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Telephone | 828-698-0896
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Fax | 828-698-9532
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Provider Business Mailing Address
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Address Line | 1334 ASHEVILLE HWY
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City | HENDERSONVILLE
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State | NC
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Zip | 28791-3414
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Country | US
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Telephone | 828-698-0896
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Fax | 828-698-9532
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Authorized Official
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Title or Position | PROVIDER
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Name | DR. RUSTAN JOEL VAN WYK
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Credential | D.O.
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Telephone | 828-698-0896
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 200001545
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License Number State | NC
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