Provider Demographics
NPI:1740235597
Name:ADVANCED ADULT & PEDIATRIC UROLOGY LLC
Entity Type:Organization
Organization Name:ADVANCED ADULT & PEDIATRIC UROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAHBANDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-797-5090
Mailing Address - Street 1:300 MERCER ST
Mailing Address - Street 2:APT 22D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-6724
Mailing Address - Country:US
Mailing Address - Phone:617-797-5090
Mailing Address - Fax:212-228-3438
Practice Address - Street 1:300 MERCER ST
Practice Address - Street 2:APT 22D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-6724
Practice Address - Country:US
Practice Address - Phone:617-797-5090
Practice Address - Fax:212-228-3438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA76499174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG73031Medicare UPIN
NJ098308Medicare ID - Type Unspecified