MEDICARE: CHILDRENS UROLOGY GROUP PL

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	2088P0231X	Pediatric 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	:	1194836239
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILDRENS UROLOGY GROUP PL

Provider Business Mailing Address
First Line	:	4712 N ARMENIA AVE
Second Line	:	SUITE 200
City	:	TAMPA
State	:	FL
Zip	:	33603-2611
Country	:	US
Telephone Number	:	813-874-7500
Fax Number	:	813-877-1397

Provider Business Practice Location Address
First Line	:	4712 N ARMENIA AVE
Second Line	:	SUITE 200
City	:	TAMPA
State	:	FL
Zip	:	33603-2611
Country	:	US
Telephone Number	:	813-874-7500
Fax Number	:	813-877-1397

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	MS. THERESA KOLLNER
Credential	:
Telephone Number	:	813-874-7500

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	07/08/2015

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