Cullman Urology, P.C.

Contacts

Phone	+1 256-739-2885
Fax	2567392898

Authorized person

Name	MS. DENISE GILLEY
Role	OFFICE MANAGER
Phone	2567392885

Taxonomy

Taxonomy Code	208800000X - Urology Physician
Is Primary	Yes

Other Provider Identifiers

Issuer	MEDICAID
Number	529302990
State	AL
Issuer	BC-BS OF ALABAMA GROUP #
Number	D472
State	AL

File	View Page
Three-digit plan number (PN)	003
Effective date of plan	1994-01-01
Business code	621111
Sponsor’s telephone number	2567392885
Plan sponsor’s address	1848 PARKLAND DRIVE N.E., CULLMAN, AL, 35058

Signature of

Role	Plan administrator
Date	2014-07-24
Name of individual signing	JAMES W. DAVIS

File	View Page
Three-digit plan number (PN)	003
Effective date of plan	1994-01-01
Business code	621111
Sponsor’s telephone number	2567392885
Plan sponsor’s address	1948 ALABAMA HWY 157, STE 450, CULLMAN, AL, 35055

Plan administrator’s name and address

Administrator’s EIN	630725909
Plan administrator’s name	CULLMAN UROLOGY, P.A.
Plan administrator’s address	1948 ALABAMA HWY 157, STE 450, CULLMAN, AL, 35055
Administrator’s telephone number	2567392885

Signature of

Role	Plan administrator
Date	2010-07-27
Name of individual signing	JAMES W. DAVIS