Provider Demographics
NPI:1497281687
Name:GUAM UROLOGY, LLC
Entity Type:Organization
Organization Name:GUAM UROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:671-646-8765
Mailing Address - Street 1:633 GOV CARLOS G CAMACHO RD
Mailing Address - Street 2:#104
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-3194
Mailing Address - Country:US
Mailing Address - Phone:671-646-8765
Mailing Address - Fax:671-646-8763
Practice Address - Street 1:633 GOV CARLOS G CAMACHO RD
Practice Address - Street 2:#104
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3194
Practice Address - Country:US
Practice Address - Phone:671-646-8765
Practice Address - Fax:671-646-8763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-07
Last Update Date:2017-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUM-1855208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty