Provider Demographics
NPI:1821027905
Name:PRINCETON UROLOGICAL GROUP INC
Entity Type:Organization
Organization Name:PRINCETON UROLOGICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-425-3761
Mailing Address - Street 1:508 NEW HOPE RD
Mailing Address - Street 2:STE 207
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2264
Mailing Address - Country:US
Mailing Address - Phone:304-425-3761
Mailing Address - Fax:304-487-3654
Practice Address - Street 1:508 NEW HOPE RD
Practice Address - Street 2:STE 207
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2264
Practice Address - Country:US
Practice Address - Phone:304-425-3761
Practice Address - Fax:304-487-3654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0130754000Medicaid
9161922Medicare ID - Type Unspecified