Provider Demographics
NPI:1710126032
Name:ASSOCIATED UROLOGICAL SPECIALISTS LLC
Entity Type:Organization
Organization Name:ASSOCIATED UROLOGICAL SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-608-2195
Mailing Address - Street 1:16522 106TH CT
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-4547
Mailing Address - Country:US
Mailing Address - Phone:708-590-8770
Mailing Address - Fax:
Practice Address - Street 1:10400 SOUTHWEST HWY
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-1367
Practice Address - Country:US
Practice Address - Phone:708-581-7308
Practice Address - Fax:708-274-4027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-10
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0769902085R0001X
IL036-120732208800000X
IL036-094573208800000X
IL036-257763208800000X
IL036-096031208800000X
IL036-102534208800000X
IL036-0623382088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02232706OtherBCBS
211475Medicare PIN
IL02232706OtherBCBS