Provider Demographics
NPI:1174703623
Name:NORTH CENTRAL UROLOGY PA
Entity type:Organization
Organization Name:NORTH CENTRAL UROLOGY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:J
Authorized Official - Middle Name:
Authorized Official - Last Name:NOVITSKI
Authorized Official - Suffix:
Authorized Official - Credentials:BSBA
Authorized Official - Phone:817-283-1860
Mailing Address - Street 1:4218 GATEWAY DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034
Mailing Address - Country:US
Mailing Address - Phone:817-283-1860
Mailing Address - Fax:817-283-2175
Practice Address - Street 1:4218 GATEWAY DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034
Practice Address - Country:US
Practice Address - Phone:817-283-1860
Practice Address - Fax:817-283-2175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0705208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170333202Medicaid
DC1932OtherMEDICARE RR
P00153491OtherMEDICARE RR
TX170333203Medicaid
TX170333201Medicaid
00957WMedicare PIN
TX170333202Medicaid
DC1932OtherMEDICARE RR
TX170333203Medicaid