Provider Demographics
NPI:1336439645
Name:ACADEMIC UROLOGY OF PA, LLC
Entity Type:Organization
Organization Name:ACADEMIC UROLOGY OF PA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-382-5910
Mailing Address - Street 1:211 S GULPH RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3112
Mailing Address - Country:US
Mailing Address - Phone:610-382-5910
Mailing Address - Fax:610-382-5918
Practice Address - Street 1:919 CONESTOGA RD
Practice Address - Street 2:BUILDING 1 SUITE 300
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-1352
Practice Address - Country:US
Practice Address - Phone:610-525-6580
Practice Address - Fax:610-525-3664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-08
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA50421501261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical