Provider Demographics
NPI:1659378602
Name:JASPER UROLOGY ASSOCIATES
Entity Type:Organization
Organization Name:JASPER UROLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT ( OWNER )
Authorized Official - Prefix:DR
Authorized Official - First Name:MAGED
Authorized Official - Middle Name:RAMZY
Authorized Official - Last Name:BOTROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-384-6835
Mailing Address - Street 1:215 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951-4440
Mailing Address - Country:US
Mailing Address - Phone:409-384-6835
Mailing Address - Fax:409-384-4159
Practice Address - Street 1:215 E WATER ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-4440
Practice Address - Country:US
Practice Address - Phone:409-384-6835
Practice Address - Fax:409-384-4159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-06
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7787208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D0484054OtherCLIA ID NUMBER
TX141628101Medicaid
TX00996KMedicare PIN
TXB21418Medicare UPIN