Provider Demographics
NPI:1609161207
Name:UROLOGIC CONSULTANTS OF SOUTHEASTERN PENNSYLVANIA, LLP
Entity Type:Organization
Organization Name:UROLOGIC CONSULTANTS OF SOUTHEASTERN PENNSYLVANIA, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:P
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-667-3020
Mailing Address - Street 1:1 PRESIDENTIAL BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1017
Mailing Address - Country:US
Mailing Address - Phone:610-667-3020
Mailing Address - Fax:610-667-1817
Practice Address - Street 1:1 PRESIDENTIAL BLVD
Practice Address - Street 2:STE 100
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1017
Practice Address - Country:US
Practice Address - Phone:610-667-3020
Practice Address - Fax:610-667-1817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-13
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA110709OtherMEDICARE GROUP PTAN
PADF9637OtherRAILROAD MEDICARE PTAN
PA16408OtherCIGNA-HEALTHSPRING
PA1930192OtherBLUE SHIELD
PA2800927000OtherINDEPENDENCE BLUE CROSS
PA1018621670001Medicaid