Provider Demographics
NPI:1639370273
Name:THE ADULT & PEDIATRIC UROLOGY GRP OF MD
Entity type:Organization
Organization Name:THE ADULT & PEDIATRIC UROLOGY GRP OF MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTROUNNI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-646-0330
Mailing Address - Street 1:9055 CHEVROLET DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-4016
Mailing Address - Country:US
Mailing Address - Phone:410-465-7533
Mailing Address - Fax:
Practice Address - Street 1:9055 CHEVROLET DR
Practice Address - Street 2:SUITE 201
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-4016
Practice Address - Country:US
Practice Address - Phone:410-465-7533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty