Provider Demographics
NPI:1952469728
Name:PEDIATRIC UROLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:PEDIATRIC UROLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC UROLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHAPIRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-649-8991
Mailing Address - Street 1:87 SCRIPPS DR
Mailing Address - Street 2:SUITE 114
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-6372
Mailing Address - Country:US
Mailing Address - Phone:916-649-8991
Mailing Address - Fax:
Practice Address - Street 1:87 SCRIPPS DR
Practice Address - Street 2:SUITE 114
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-6372
Practice Address - Country:US
Practice Address - Phone:916-649-8991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG222052088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0069580Medicaid
CAA41508Medicare UPIN