MEDICARE: UROLOGIC INTEGRATED CARE LLC

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
1	208800000X	Urology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104392232
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UROLOGIC INTEGRATED CARE LLC

Provider Business Mailing Address
First Line	:	5745 SW 75TH ST # 507
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32608-5504
Country	:	US
Telephone Number	:	352-204-5400
Fax Number	:	352-204-5405

Provider Business Practice Location Address
First Line	:	1201 NW 64TH TER
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32605-4220
Country	:	US
Telephone Number	:	352-204-5400
Fax Number	:	352-204-5405

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. VICTORIA Y BIRD
Credential	:	MD
Telephone Number	:	352-278-5132

Provider Enumeration Date	:	10/16/2018
Last Update Date	:	11/15/2018

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