Provider Demographics
NPI:1083708283
Name:AMSTERDAM UROLOGY ASSOCIATES PC
Entity Type:Organization
Organization Name:AMSTERDAM UROLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:REZA
Authorized Official - Last Name:GHAZI-MOGHADAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-843-1449
Mailing Address - Street 1:425 GUY PARK AVENUE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010
Mailing Address - Country:US
Mailing Address - Phone:518-843-1449
Mailing Address - Fax:518-843-8215
Practice Address - Street 1:425 GUY PARK AVENUE
Practice Address - Street 2:SUITE 203
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010
Practice Address - Country:US
Practice Address - Phone:518-843-1449
Practice Address - Fax:518-843-8215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1326381208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
24109OtherMVP
NY00557268Medicaid
10000753OtherCDPHP
24109OtherMVP
10000753OtherCDPHP