=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740450899
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UROLOGY CENTER OF SOUTHWEST VIRGINIA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2008
-----------------------------------------------------
Last Update Date | 11/28/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 390 COMMERCE DR
-----------------------------------------------------
City | ABINGDON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24211-3876
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-623-0500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 390 COMMERCE DR
-----------------------------------------------------
City | ABINGDON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24211-3876
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-623-0500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. MARISOL SPIEGEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 276-623-0500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 0101058458
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------