CITRUS UROLOGY ASSOCIATES, P.A.

Contacts

Phone	+1 352-742-2201
Fax	3527422226

Authorized person

Name	DR. CHARLES K CARTWRIGHT
Role	DIRECTOR
Phone	3527422201

Taxonomy

Taxonomy Code	208800000X - Urology Physician
License Number	10D1018775
State	FL
Is Primary	Yes

Other Provider Identifiers

Issuer	RAILROAD MEDICARE
Number	DA4769
State	FL
Issuer	MEDICAID
Number	0604763000
State	FL
Issuer	BLUE CROSS BLUE SHEILD
Number	98224
State	FL

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	1978-10-01
Business code	621111
Sponsor’s telephone number	3523916000
Plan sponsor’s address	12109 COUNTY ROAD 103, OXFORD, FL, 34484

Plan administrator’s name and address

Administrator’s EIN	591842276
Plan administrator’s name	CITRUS UROLOGY ASSOCIATES, P.A.
Plan administrator’s address	12109 COUNTY ROAD 103, OXFORD, FL, 34484
Administrator’s telephone number	3523916000

Signature of

Role	Plan administrator
Date	2011-10-14
Name of individual signing	TATIANA POMBO
Valid signature	Filed with authorized/valid electronic signature
Role	Employer/plan sponsor
Date	2011-10-14
Name of individual signing	TATIANA POMBO
Valid signature	Filed with authorized/valid electronic signature

File	View Page
Three-digit plan number (PN)	002
Effective date of plan	1978-10-01
Business code	621111
Sponsor’s telephone number	3523916000
Plan sponsor’s address	12109 COUNTY ROAD 103, OXFORD, FL, 34484

Plan administrator’s name and address

Administrator’s EIN	591842276
Plan administrator’s name	CITRUS UROLOGY ASSOCIATES, P.A.
Plan administrator’s address	12109 COUNTY ROAD 103, OXFORD, FL, 34484
Administrator’s telephone number	3523916000

Signature of

Role	Plan administrator
Date	2010-10-13
Name of individual signing	JULIE BURGESS
Valid signature	Filed with authorized/valid electronic signature