Provider Demographics
NPI:1225193162
Name:JERSEY UROLOGY GROUP P. A.
Entity Type:Organization
Organization Name:JERSEY UROLOGY GROUP P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL ADVISOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:PISKUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-927-8746
Mailing Address - Street 1:403 BETHEL RD
Mailing Address - Street 2:
Mailing Address - City:SOMERS POINT
Mailing Address - State:NJ
Mailing Address - Zip Code:08244-2108
Mailing Address - Country:US
Mailing Address - Phone:609-927-8746
Mailing Address - Fax:609-653-8807
Practice Address - Street 1:403 BETHEL RD
Practice Address - Street 2:
Practice Address - City:SOMERS POINT
Practice Address - State:NJ
Practice Address - Zip Code:08244-2108
Practice Address - Country:US
Practice Address - Phone:609-927-8746
Practice Address - Fax:609-601-1406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08050100208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========OtherTAX ID#
106682Medicare UPIN