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General NPI Number Information
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NPI Number | 1376593061
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Entity Type | Organization
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Legal Business Name | PEDIATRIC UROLOGY ASSOCIATES
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Dates
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Enumeration Date | 05/11/2006
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Last Update Date | 08/05/2015
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Provider Practice Location Address
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Address Line | 3135 SPRINGBANK LANE SUITE 200
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City | CHARLOTTE
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State | NC
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Zip | 28226-3360
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Country | US
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Telephone | 704-540-3667
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Fax | 704-540-3668
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Provider Business Mailing Address
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Address Line | 3135 SPRINGBANK LANE SUITE 200
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City | CHARLOTTE
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State | NC
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Zip | 28226-3360
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Country | US
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Telephone | 704-540-3667
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Fax | 704-540-3668
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Authorized Official
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Title or Position | COO
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Name | DR. JOSEPH A. MOLITIESM JR.
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Credential | M.D.
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Telephone | 407-540-3667
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 1000392
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 103556
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 9600282
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License Number State | NC
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