=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619927100
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DANVILLE UROLOGIC CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2006
-----------------------------------------------------
Last Update Date | 09/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1040 MAIN ST
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24541-1816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-792-1433
-----------------------------------------------------
Fax | 434-797-2807
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1040 MAIN ST P.O. BOX 1360
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24541-1816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 434-792-1433
-----------------------------------------------------
Fax | 434-797-2807
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOSEPH M CARBONE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 434-792-1433
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------