Provider Demographics
NPI:1558399568
Name:PENINSULA UROLOGY CENTER INC
Entity Type:Organization
Organization Name:PENINSULA UROLOGY CENTER INC
Other - Org Name:CHRIS THREATT, MD, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:THREATT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-306-1016
Mailing Address - Street 1:2900 WHIPPLE AVE
Mailing Address - Street 2:SUITE 132
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94062-2843
Mailing Address - Country:US
Mailing Address - Phone:650-306-1016
Mailing Address - Fax:650-369-3627
Practice Address - Street 1:2900 WHIPPLE AVE
Practice Address - Street 2:SUITE 132
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94062-2843
Practice Address - Country:US
Practice Address - Phone:650-306-1016
Practice Address - Fax:650-369-3627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79072208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ01293ZMedicare ID - Type Unspecified