Provider Demographics
NPI:1437806197
Name:MODERN UROLOGY GROUP LLC
Entity Type:Organization
Organization Name:MODERN UROLOGY GROUP LLC
Other - Org Name:MODERN UROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DE FAZIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-770-1666
Mailing Address - Street 1:13025 SW 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:PINECREST
Mailing Address - State:FL
Mailing Address - Zip Code:33156-7115
Mailing Address - Country:US
Mailing Address - Phone:305-215-3213
Mailing Address - Fax:
Practice Address - Street 1:3400 CORAL WAY STE 500
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-3053
Practice Address - Country:US
Practice Address - Phone:305-603-8684
Practice Address - Fax:833-756-2656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-03
Last Update Date:2022-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1093127631Medicaid