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General NPI Number Information
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NPI Number | 1083831804
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Entity Type | Organization
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Legal Business Name | COOSA VALLEY UROLOGY, P.C.
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Dates
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Enumeration Date | 04/20/2007
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Last Update Date | 10/04/2013
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Provider Practice Location Address
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Address Line | 16 SOUTH DOUGLAS AVENUE
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City | SYLACAUGA
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State | AL
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Zip | 35150
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Country | US
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Telephone | 256-245-2269
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Fax | 256-245-2260
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Provider Business Mailing Address
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Address Line | 16 SOUTH DOUGLAS AVENUE
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City | SYLACAUGA
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State | AL
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Zip | 35150
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Country | US
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Telephone | 256-245-2269
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Fax | 256-245-2260
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Authorized Official
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Title or Position | OWNER
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Name | DR. MAMOUN R PACHA
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Credential | M.D.
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Telephone | 256-245-2269
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 8767
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License Number State | AL
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