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General NPI Number Information
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NPI Number | 1265437743
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Entity Type | Organization
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Legal Business Name | REGIONAL UROLOGY ASC LLC
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Dates
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Enumeration Date | 06/20/2005
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Last Update Date | 01/07/2022
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Provider Practice Location Address
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Address Line | 255 BERT KOUNS LOOP
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City | SHREVEPORT
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State | LA
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Zip | 71106-8150
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Country | US
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Telephone | 318-683-0411
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Fax | 318-603-5461
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Provider Business Mailing Address
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Address Line | 255 BERT KOUNS LOOP
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City | SHREVEPORT
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State | LA
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Zip | 71106-8150
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Country | US
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Telephone | 318-683-0411
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Fax |
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Authorized Official
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Title or Position | BOARD MEMBER
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Name | THOMAS E PALMER
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Credential | MD
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Telephone | 318-683-0411
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 100
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License Number State | LA
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