Provider Demographics
NPI:1689903882
Name:MYSTIC VALLEY UROLOGICAL ASSOC INC
Entity Type:Organization
Organization Name:MYSTIC VALLEY UROLOGICAL ASSOC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MARJIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HALUSKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-979-0661
Mailing Address - Street 1:3 WOODLAND RD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-1702
Mailing Address - Country:US
Mailing Address - Phone:781-979-0661
Mailing Address - Fax:781-979-0372
Practice Address - Street 1:3 WOODLAND RD
Practice Address - Street 2:SUITE 216
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-1702
Practice Address - Country:US
Practice Address - Phone:781-979-0661
Practice Address - Fax:781-979-0372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-17
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0009638OtherNHP
MA9723757Medicaid
MAM13568OtherBCBSMA
MAM13568OtherMEDICARE ID-TYPE UNSPECIFIED
MA9723757OtherNETWORK HEALTH
MA28749OtherFALLON
MA600296OtherTUFTS
MACL0638OtherRRMED