Provider Demographics
NPI:1770516908
Name:CHILDRENS UROLOGY ASSOCIATES PA
Entity type:Organization
Organization Name:CHILDRENS UROLOGY ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EDDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-669-6448
Mailing Address - Street 1:3200 SW 60TH CT
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-4000
Mailing Address - Country:US
Mailing Address - Phone:305-669-6448
Mailing Address - Fax:305-663-8485
Practice Address - Street 1:3200 SW 60TH CT
Practice Address - Street 2:SUITE 104
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-4000
Practice Address - Country:US
Practice Address - Phone:305-669-6448
Practice Address - Fax:305-663-8485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL38599OtherBLUE CROSS BLUE SHIELD
FL255861100Medicaid
FL38599Medicare PIN