Provider Demographics
NPI:1134253982
Name:SUBURBAN UROLOGICAL, PC
Entity type:Organization
Organization Name:SUBURBAN UROLOGICAL, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:MINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-884-7114
Mailing Address - Street 1:3 VILLAGE ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HORSHAM
Mailing Address - State:PA
Mailing Address - Zip Code:19044-3812
Mailing Address - Country:US
Mailing Address - Phone:215-884-7114
Mailing Address - Fax:215-884-7147
Practice Address - Street 1:3 VILLAGE ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:HORSHAM
Practice Address - State:PA
Practice Address - Zip Code:19044-3812
Practice Address - Country:US
Practice Address - Phone:215-884-7114
Practice Address - Fax:215-884-7147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011791720001Medicaid
517274Medicare PIN