MEDICARE: PULASKI 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

General Provider Information

NPI Number	:	1457393852
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PULASKI UROLOGY, LLC

Provider Business Mailing Address
First Line	:	2460 LEE HWY N
Second Line	:	SUITE 5
City	:	PULASKI
State	:	VA
Zip	:	24301-2335
Country	:	US
Telephone Number	:	540-980-3914
Fax Number	:

Provider Business Practice Location Address
First Line	:	2460 LEE HWY N
Second Line	:	SUITE 5
City	:	PULASKI
State	:	VA
Zip	:	24301-2335
Country	:	US
Telephone Number	:	540-980-3914
Fax Number	:

Authorized Official
Title or Position	:	VP
Name	:	CAROL SMITH
Credential	:
Telephone Number	:	540-980-3914

Provider Enumeration Date	:	06/11/2006
Last Update Date	:	08/22/2020

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