Provider Demographics
NPI:1235240920
Name:SOUTHEAST VALLEY UROLOGY PC
Entity Type:Organization
Organization Name:SOUTHEAST VALLEY UROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CROUSHORE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:480-924-7333
Mailing Address - Street 1:6344 E BROADWAY RD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1634
Mailing Address - Country:US
Mailing Address - Phone:480-924-7333
Mailing Address - Fax:
Practice Address - Street 1:6344 E BROADWAY RD
Practice Address - Street 2:SUITE 112
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1634
Practice Address - Country:US
Practice Address - Phone:480-924-7333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
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
AZWDCCDMedicare ID - Type Unspecified