Provider Demographics
NPI:1508814138
Name:GLEN-WHITE UROLOGICAL MEDICAL GROUP INC
Entity Type:Organization
Organization Name:GLEN-WHITE UROLOGICAL MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SZE-CHING
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-242-1144
Mailing Address - Street 1:1560 EAST CHEVY CHASE DR
Mailing Address - Street 2:SUITE 325
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206
Mailing Address - Country:US
Mailing Address - Phone:818-242-1144
Mailing Address - Fax:818-242-6948
Practice Address - Street 1:1560 EAST CHEVY CHASE DR
Practice Address - Street 2:SUITE 325
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206
Practice Address - Country:US
Practice Address - Phone:818-242-1144
Practice Address - Fax:818-242-6948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0065130Medicaid
CAG9410927Medicaid
CAGR0065131Medicaid
CAW1259Medicare ID - Type Unspecified
CAW1259AMedicare ID - Type Unspecified
CAGR0065131Medicaid