=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700985272
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAHLONEGA UROLOGY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2006
-----------------------------------------------------
Last Update Date | 02/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39 WILD RIDGE LN
-----------------------------------------------------
City | DAHLONEGA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30533-9109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-497-6898
-----------------------------------------------------
Fax | 518-497-6903
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 382
-----------------------------------------------------
City | DAHLONEGA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30533-0007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-497-6898
-----------------------------------------------------
Fax | 518-497-6903
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | UROLOGIST
-----------------------------------------------------
Name | DR. JULIO MANUEL OSSORIO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 518-497-6898
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 054175
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------