MTN Lake Urology PC

Primary specialty

SpecialistTaxonomy code 174400000X

License

17993 Issued in AL

Legal business name

MTN LAKE UROLOGY PC

Practice address

750 Byron Rd
Scottsboro, AL 35769-4051

Phone

(256) 259-8765

Fax

(256) 716-8060

NPI assigned

Jul 14, 2008

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Sherry Gross

Title

Office Manager

Phone

(256) 259-8765

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in AL

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Kerry Dale Walker, CRNP

  • Family Nurse Practitioner
  • Scottsboro, AL
  • NPI 1427945476
  Medicare reassignment Care Compare group NPD
• Michael Grayson Simmons, MD

  • Urology Physician
  • Gainesville, GA
  • NPI 1225023344

  AL

  Medicare reassignment Care Compare group NPD
• Jennifer Simmons, CRNP

  • Acute Care Nurse Practitioner
  • Scottsboro, AL
  • NPI 1184054603
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1215993600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1521590400000",
    "number": "1801050364",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "750 BYRON RD",
            "city": "SCOTTSBORO",
            "state": "AL",
            "postal_code": "357694051",
            "telephone_number": "256-259-8765",
            "fax_number": "256-716-8060"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "750 BYRON RD",
            "city": "SCOTTSBORO",
            "state": "AL",
            "postal_code": "357694051",
            "telephone_number": "256-259-8765",
            "fax_number": "256-716-8060"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MTN LAKE UROLOGY PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-07-14",
        "last_updated": "2018-03-21",
        "status": "A",
        "authorized_official_last_name": "GROSS",
        "authorized_official_first_name": "SHERRY",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "256-259-8765"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": "AL",
            "license": "17993",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "106277",
            "state": "AL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Kristal Moman, OT
• Tisha Woods Morgan
• Margaret S Morr, MD
• Houston Lane Morrow
• Jessica Moss, CRNP
• Muhammad Ejaz Ata (Scottsboro Medical Clinic)
• Muhammad Ejaz Ata, M.D (Pisgah Medical Clinic Scottsboro Medical Clinic Muhammad Ejaz Ata MD)
• James Edward Murphree Jr., MS
• Amanda Necklaus, LMT
• Bethany Johnson Nemati, MD

• Specialist in Scottsboro, AL
• Providers in Scottsboro, AL by specialty
• Specialist in Alabama

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 21, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.