Provider Demographics
NPI:1982690731
Name:CHARLES RIVER UROLOGY INC
Entity Type:Organization
Organization Name:CHARLES RIVER UROLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:DRETLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-726-3512
Mailing Address - Street 1:15 PARKMAN ST
Mailing Address - Street 2:SUITE 486
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-3117
Mailing Address - Country:US
Mailing Address - Phone:617-726-3512
Mailing Address - Fax:617-726-3519
Practice Address - Street 1:15 PARKMAN ST
Practice Address - Street 2:SUITE 486
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-3117
Practice Address - Country:US
Practice Address - Phone:617-726-3512
Practice Address - Fax:617-726-3519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA29066208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9708979Medicaid
MA9708979Medicaid