Provider Demographics
NPI:1588822423
Name:NEW JERSEY UROLOGY LLC
Entity Type:Organization
Organization Name:NEW JERSEY UROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:HOUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-873-7000
Mailing Address - Street 1:1515 BROAD ST
Mailing Address - Street 2:SUITE B130
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3002
Mailing Address - Country:US
Mailing Address - Phone:973-873-7000
Mailing Address - Fax:973-743-8943
Practice Address - Street 1:1515 BROAD ST
Practice Address - Street 2:SUITE B130
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3002
Practice Address - Country:US
Practice Address - Phone:973-873-7000
Practice Address - Fax:973-743-8943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-28
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA020509002085R0001X, 208800000X
291U00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical Laboratory
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D08754OtherMEDICARE RAILROAD
31D1104853OtherCLIA
D08754OtherMEDICARE RAILROAD
NJ6270570001Medicare NSC