MEDICARE: SOUTHERN 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	:	1467160234
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN UROLOGY LLC

Provider Business Mailing Address
First Line	:	602 SAINT LANDRY ST
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70506-4628
Country	:	US
Telephone Number	:	337-235-1200
Fax Number	:

Provider Business Practice Location Address
First Line	:	602 SAINT LANDRY ST
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70506-4628
Country	:	US
Telephone Number	:	337-235-1200
Fax Number	:

Authorized Official
Title or Position	:	AO
Name	:	MARK ROBERT ELDREDGE
Credential	:
Telephone Number	:	337-769-7779

Provider Enumeration Date	:	11/10/2022
Last Update Date	:	03/13/2023

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Directions to “SOUTHERN UROLOGY LLC ” Practice Location

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