Provider Demographics
NPI:1871648188
Name:ASSOCIATEDUROLOGY MEDICAL GROUP,INC.
Entity Type:Organization
Organization Name:ASSOCIATEDUROLOGY MEDICAL GROUP,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NARAYANA
Authorized Official - Middle Name:VENKATA
Authorized Official - Last Name:BULUSU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-889-1700
Mailing Address - Street 1:20130 LAKE CHABOT RD
Mailing Address - Street 2:# 302
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-5340
Mailing Address - Country:US
Mailing Address - Phone:510-889-1700
Mailing Address - Fax:510-889-7170
Practice Address - Street 1:20130 LAKE CHABOT RD
Practice Address - Street 2:# 302
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5340
Practice Address - Country:US
Practice Address - Phone:510-889-1700
Practice Address - Fax:510-889-7170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30679208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ03499ZMedicare ID - Type UnspecifiedMEDICAL CORPORATION