Provider Demographics
NPI:1043412265
Name:UROLOGIC ASSOCIATES OF WILKES BARRE INC
Entity Type:Organization
Organization Name:UROLOGIC ASSOCIATES OF WILKES BARRE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HARAGOPAL
Authorized Official - Middle Name:
Authorized Official - Last Name:PENUGONDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-288-4551
Mailing Address - Street 1:470 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3603
Mailing Address - Country:US
Mailing Address - Phone:570-288-4551
Mailing Address - Fax:570-287-7999
Practice Address - Street 1:470 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-3603
Practice Address - Country:US
Practice Address - Phone:570-288-4551
Practice Address - Fax:570-287-7999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA070927Medicare ID - Type Unspecified