Provider Demographics
NPI:1588802961
Name:UROLOGIC SURGERY ASSOCIATES
Entity Type:Organization
Organization Name:UROLOGIC SURGERY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HIBBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-822-2727
Mailing Address - Street 1:11179 IVY CREEK CV
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-2249
Mailing Address - Country:US
Mailing Address - Phone:801-822-2727
Mailing Address - Fax:
Practice Address - Street 1:11179 IVY CREEK CV
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-2249
Practice Address - Country:US
Practice Address - Phone:801-822-2727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7100427-1205261QL0400X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QL0400XAmbulatory Health Care FacilitiesClinic/CenterLithotripsy