Provider Demographics
NPI:1336365873
Name:UNIVERSITY UROLOGICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:UNIVERSITY UROLOGICAL ASSOCIATES, INC.
Other - Org Name:COLLYER STREET OPERATORY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:DEROCHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-276-2001
Mailing Address - Street 1:195 COLLYER STREET
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904
Mailing Address - Country:US
Mailing Address - Phone:401-276-2026
Mailing Address - Fax:401-276-2025
Practice Address - Street 1:195 COLLYER ST
Practice Address - Street 2:SUITE 201
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-1869
Practice Address - Country:US
Practice Address - Phone:401-276-2026
Practice Address - Fax:401-276-2025
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSTIY UROLOGICAL ASSOCIATES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-17
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPHS00006208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI000005723OtherBLUE CROSS BLUE SHIELD
RI000005723OtherBLUE CROSS BLUE SHIELD