MEDICARE: STARKVILLE UROLOGY, PLLC

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	17324	MS

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	:	1639374218
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STARKVILLE UROLOGY, PLLC

Provider Business Mailing Address
First Line	:	1207 HIGHWAY 182 W STE B
Second Line	:
City	:	STARKVILLE
State	:	MS
Zip	:	39759-9013
Country	:	US
Telephone Number	:	662-324-1097
Fax Number	:	662-324-2412

Provider Business Practice Location Address
First Line	:	1207 HIGHWAY 182 W STE B
Second Line	:
City	:	STARKVILLE
State	:	MS
Zip	:	39759-9013
Country	:	US
Telephone Number	:	662-324-1097
Fax Number	:	662-324-2412

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	DONACIANA INGRAM
Credential	:
Telephone Number	:	662-324-1097

Provider Enumeration Date	:	06/15/2007
Last Update Date	:	08/21/2020

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