Provider Demographics
NPI:1225073588
Name:VALLEY ASSOCIATED UROLOGY MEDICARE GROUP INC
Entity Type:Organization
Organization Name:VALLEY ASSOCIATED UROLOGY MEDICARE GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYAJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-521-0870
Mailing Address - Street 1:1541 FLORIDA AVE
Mailing Address - Street 2:STE 306
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4429
Mailing Address - Country:US
Mailing Address - Phone:209-521-0870
Mailing Address - Fax:209-521-0398
Practice Address - Street 1:200 COTTAGE AVE
Practice Address - Street 2:STE 101
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4935
Practice Address - Country:US
Practice Address - Phone:209-239-2197
Practice Address - Fax:209-239-7672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0066264Medicaid
CAGR0066264Medicaid