MEDICARE: NORTH PLATTE REGIONAL 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	20757	NE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1356311583	OTHER		PERSONAL NPI

General Provider Information

NPI Number	:	1497892673
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTH PLATTE REGIONAL UROLOGY, LLC

Provider Business Mailing Address
First Line	:	4455 STONEHAVEN DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-4897
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	611 W FRANCIS ST
Second Line	:
City	:	NORTH PLATTE
State	:	NE
Zip	:	69101-0620
Country	:	US
Telephone Number	:	719-393-2137
Fax Number	:

Authorized Official
Title or Position	:	UROLOGIST SOLE PROPRIETOR OWNER
Name	:	MICHAEL GALLENTINE
Credential	:
Telephone Number	:	719-393-2137

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	08/22/2020

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Directions to “NORTH PLATTE REGIONAL UROLOGY, LLC ” Practice Location

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