Provider Demographics
NPI:1629167986
Name:UROLOGICAL ASSOCIATES OF BELLEVILLE IL LTD
Entity Type:Organization
Organization Name:UROLOGICAL ASSOCIATES OF BELLEVILLE IL LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:STANCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:618-233-2603
Mailing Address - Street 1:301 W LINCOLN ST STE 57
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1901
Mailing Address - Country:US
Mailing Address - Phone:618-233-2603
Mailing Address - Fax:618-233-0413
Practice Address - Street 1:301 W LINCOLN ST STE 57
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1901
Practice Address - Country:US
Practice Address - Phone:618-233-2603
Practice Address - Fax:618-233-0413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL289630OtherMEDICARE GROUP NUMBER
IL289630OtherMEDICARE GROUP NUMBER