Provider Demographics
NPI:1740536531
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:610-525-6580
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 1:211 S GULPH RD
Practice Address - Street 2:SUITE 200
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-3112
Practice Address - Country:US
Practice Address - Phone:610-382-5910
Practice Address - Fax:610-382-5918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031222E207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA118334Medicare PIN