Provider Demographics
NPI:1467578732
Name:WATERSHED UROLOGY, P.C.
Entity Type:Organization
Organization Name:WATERSHED UROLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:V
Authorized Official - Last Name:GRONKIEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-241-2200
Mailing Address - Street 1:9 BROOKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17015-9126
Mailing Address - Country:US
Mailing Address - Phone:717-241-2200
Mailing Address - Fax:717-245-9611
Practice Address - Street 1:9 BROOKWOOD AVE
Practice Address - Street 2:
Practice Address - City:CARLISLE
Practice Address - State:PA
Practice Address - Zip Code:17015-9126
Practice Address - Country:US
Practice Address - Phone:717-241-2200
Practice Address - Fax:717-245-9611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD050185L208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADB4793OtherRAILROAD MEDICARE
PADB4793OtherRAILROAD MEDICARE