Provider Demographics
NPI:1306209200
Name:GULFSHORE UROLOGY LLC
Entity Type:Organization
Organization Name:GULFSHORE UROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SHAREHOLDER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-333-3200
Mailing Address - Street 1:28930 TRAILS EDGE BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-7582
Mailing Address - Country:US
Mailing Address - Phone:239-333-3200
Mailing Address - Fax:239-992-5785
Practice Address - Street 1:28930 TRAILS EDGE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-7582
Practice Address - Country:US
Practice Address - Phone:239-333-3200
Practice Address - Fax:239-992-5785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty