Provider Demographics
NPI:1871635789
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:708-274-4027
Practice Address - Street 1:15300 WEST AVE
Practice Address - Street 2:WEST BUILDING SUITE 314
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4600
Practice Address - Country:US
Practice Address - Phone:708-364-7882
Practice Address - Fax:708-364-7886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
211475Medicare PIN
5433040002Medicare NSC
C38239Medicare UPIN