Provider Demographics
NPI:1376681437
Name:ADULT & PEDIATRIC UROLOGY GROUP OF MARYLAND LLC
Entity Type:Organization
Organization Name:ADULT & PEDIATRIC UROLOGY GROUP OF MARYLAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTROUNNI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-646-0331
Mailing Address - Street 1:3455 WILKENS AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-5213
Mailing Address - Country:US
Mailing Address - Phone:410-646-0330
Mailing Address - Fax:410-644-6182
Practice Address - Street 1:3455 WILKENS AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-5213
Practice Address - Country:US
Practice Address - Phone:410-646-0330
Practice Address - Fax:410-644-6182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE612OtherCAREFIRST FEDERAL ID
MDE612OtherBLUE CHOICE GRP. ID
MD1507ADOtherCAREFIRST BCBS OF MD ID
MD033000100Medicaid
MD033000100Medicaid