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NPI Code Detail

MEDICARE: SOUTHSIDE UROLOGY CLINIC, P.C.

MEDICARE: SOUTHSIDE UROLOGY CLINIC, P.C.
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
1261QM2500XMedical Specialty Clinic/Center3478OK

General Provider Information

NPI Number : 1952778177
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTHSIDE UROLOGY CLINIC, P.C.
Provider Business Mailing Address
First Line : 9817 S WESTERN AVE
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73139-2812
Country : US
Telephone Number : 405-632-4500
Fax Number : 405-632-7500
Provider Business Practice Location Address
First Line : 9817 S WESTERN AVE
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73139-2812
Country : US
Telephone Number : 405-632-4500
Fax Number : 405-632-7500
Authorized Official
Title or Position : OWNER
Name : RAJENDRA K MOTWANI
Credential : D.O.
Telephone Number : 405-632-4500
Provider Enumeration Date : 08/24/2015
Last Update Date : 12/04/2015

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