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NPI Code Detail

MEDICARE: ATLANTIC UROLOGY PC

MEDICARE: ATLANTIC UROLOGY PC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208800000XUrology Physician

General Provider Information

NPI Number : 1073770939
Entity Type Code : Organization
Provider Name (Legal Business Name) : ATLANTIC UROLOGY PC
Provider Business Mailing Address
First Line : PO BOX 600085
Second Line :
City : RALEIGH
State : NC
Zip : 27675-6085
Country : US
Telephone Number : 910-362-8765
Fax Number :
Provider Business Practice Location Address
First Line : 4222 LONG BEACH RD SE
Second Line :
City : SOUTHPORT
State : NC
Zip : 28461-8627
Country : US
Telephone Number : 910-362-8765
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : RICHARD J MYNATT
Credential : MD
Telephone Number : 910-362-8765
Provider Enumeration Date : 05/19/2008
Last Update Date : 03/02/2009

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