Provider Demographics
NPI:1689917726
Name:CAMBRIDGE UROLOGICAL ASSOCIATES, INC
Entity Type:Organization
Organization Name:CAMBRIDGE UROLOGICAL ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:H
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:617-547-4400
Mailing Address - Street 1:300 MOUNT AUBURN ST
Mailing Address - Street 2:STE 519
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-5600
Mailing Address - Country:US
Mailing Address - Phone:617-547-4400
Mailing Address - Fax:617-576-1076
Practice Address - Street 1:790 BOSTON RD
Practice Address - Street 2:
Practice Address - City:BILLERICA
Practice Address - State:MA
Practice Address - Zip Code:01821-5938
Practice Address - Country:US
Practice Address - Phone:617-547-4400
Practice Address - Fax:617-576-1076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110067128AMedicaid
MAM020540Medicare PIN