Provider Demographics
NPI:1417288150
Name:ACADEMIC UROLOGY OF PA, LLC
Entity Type:Organization
Organization Name:ACADEMIC UROLOGY OF PA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-525-6580
Mailing Address - Street 1:919 CONESTOGA RD
Mailing Address - Street 2:BUILDING ONE, SUITE 300
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-1352
Mailing Address - Country:US
Mailing Address - Phone:610-525-6580
Mailing Address - Fax:610-525-3664
Practice Address - Street 1:125 MEDICAL CAMPUS DR
Practice Address - Street 2:MEDICAL ARTS BUILDING, SUITE 305
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-7205
Practice Address - Country:US
Practice Address - Phone:215-361-2304
Practice Address - Fax:215-361-2389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031222E208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty