Provider Demographics
NPI:1114452547
Name:MYSTIC VALLEY UROLOGICAL ASSOCIATES, INC
Entity Type:Organization
Organization Name:MYSTIC VALLEY UROLOGICAL ASSOCIATES, INC
Other - Org Name:MYSTIC VALLEY UROLOGICAL ASSOCIATES, TOO
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF BUSINESS OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MARJIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:HALUSKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-462-3040
Mailing Address - Street 1:3 WOODLAND RD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-1702
Mailing Address - Country:US
Mailing Address - Phone:781-979-0661
Mailing Address - Fax:781-979-0372
Practice Address - Street 1:3 WOODLAND RD
Practice Address - Street 2:SUITE 216
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-1702
Practice Address - Country:US
Practice Address - Phone:781-979-0661
Practice Address - Fax:781-979-0372
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MYSTIC VALLEY UROLOGICAL ASSOCIATES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM13568Medicare UPIN