Provider Demographics
NPI:1376866616
Name:PREMIER UROLOGY GROUP LLC
Entity Type:Organization
Organization Name:PREMIER UROLOGY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-679-2010
Mailing Address - Street 1:3 HOSPITAL PLZ
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-3093
Mailing Address - Country:US
Mailing Address - Phone:732-679-2010
Mailing Address - Fax:
Practice Address - Street 1:3 HOSPITAL PLZ
Practice Address - Street 2:SUITE 200
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-3093
Practice Address - Country:US
Practice Address - Phone:732-679-2010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-01
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05567600174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6351110002Medicare NSC