Provider Demographics
NPI:1942640719
Name:RODERICK M URBANIAK, M.D., P.A.
Entity Type:Organization
Organization Name:RODERICK M URBANIAK, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WIERSMA
Authorized Official - Suffix:
Authorized Official - Credentials:6162184495
Authorized Official - Phone:616-218-4495
Mailing Address - Street 1:609 LAKEVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-3335
Mailing Address - Country:US
Mailing Address - Phone:727-447-4536
Mailing Address - Fax:727-442-1600
Practice Address - Street 1:609 LAKEVIEW RD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3335
Practice Address - Country:US
Practice Address - Phone:727-447-4536
Practice Address - Fax:727-442-1600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301083724208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID16253019Medicare PIN