Provider Demographics
NPI:1477587376
Name:ADULT & PEDIATRIC UROLOGY
Entity Type:Organization
Organization Name:ADULT & PEDIATRIC UROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:P
Authorized Official - Last Name:KEATING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:320-259-1411
Mailing Address - Street 1:2351 CONNECTICUT AVENUE SOUTH
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-2011
Mailing Address - Country:US
Mailing Address - Phone:320-259-1411
Mailing Address - Fax:
Practice Address - Street 1:2351 CONNECTICUT AVENUE SOUTH
Practice Address - Street 2:SUITE 200
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2011
Practice Address - Country:US
Practice Address - Phone:320-259-1411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0687890001Medicare NSC
MNC07588Medicare ID - Type Unspecified