MEDICARE: CLINCH VALLEY UROLOGY, 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	:	1114955168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINCH VALLEY UROLOGY, LLC

Provider Business Mailing Address
First Line	:	6719 GOV G. C. PEERY HWY
Second Line	:	SUITE 3650
City	:	RICHLANDS
State	:	VA
Zip	:	24641-2055
Country	:	US
Telephone Number	:	276-596-6773
Fax Number	:	866-803-1898

Provider Business Practice Location Address
First Line	:	6719 GOV G. C. PEERY HWY
Second Line	:	SUITE 1800
City	:	RICHLANDS
State	:	VA
Zip	:	24641-2055
Country	:	US
Telephone Number	:	276-596-6659
Fax Number	:	276-596-6658

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JESS JUDY
Credential	:
Telephone Number	:	615-565-1508

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	04/14/2010

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