Provider Demographics
NPI:1851515993
Name:NORTHEASTERN OHIO UROLOGICAL SURGEONS, INC.
Entity Type:Organization
Organization Name:NORTHEASTERN OHIO UROLOGICAL SURGEONS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:T
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-823-1112
Mailing Address - Street 1:885 S SAWBURG RD
Mailing Address - Street 2:
Mailing Address - City:ALLIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:44601-5905
Mailing Address - Country:US
Mailing Address - Phone:330-823-1112
Mailing Address - Fax:330-823-1139
Practice Address - Street 1:885 S SAWBURG RD
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-5905
Practice Address - Country:US
Practice Address - Phone:330-823-1112
Practice Address - Fax:330-823-1139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35058282208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCN7807OtherRAILROAD MEDICARE GROUP NUMBER
OHC51968Medicare UPIN
OHH35365Medicare UPIN
OH9290982Medicare PIN
OH9290983Medicare PIN
OH4238110001Medicare NSC
OH9290981Medicare PIN
OHG53638Medicare UPIN