MEDICARE: CAROLINA UROLOGY CENTER, PA

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

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	:	1952561623
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINA UROLOGY CENTER, PA

Provider Business Mailing Address
First Line	:	1780 MEDICAL PARK DR
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-1194
Country	:	US
Telephone Number	:	803-327-1116
Fax Number	:	803-327-6872

Provider Business Practice Location Address
First Line	:	580 KINGSLEY PARK DR
Second Line	:	SUITE 150
City	:	FORT MILL
State	:	SC
Zip	:	29715-6403
Country	:	US
Telephone Number	:	803-578-7600
Fax Number	:	803-431-2257

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	TRACY BLACK
Credential	:
Telephone Number	:	803-327-1116

Provider Enumeration Date	:	06/16/2008
Last Update Date	:	12/02/2008

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Directions to “CAROLINA UROLOGY CENTER, PA ” Practice Location

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