Provider Demographics
NPI:1801990486
Name:UROLOGY ASSOC OF SAN ANTONIO PA
Entity type:Organization
Organization Name:UROLOGY ASSOC OF SAN ANTONIO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:ELLIOT
Authorized Official - Last Name:KRUSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-227-9376
Mailing Address - Street 1:1303 MCCULLOUGH AVE
Mailing Address - Street 2:SUITE 561
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-5668
Mailing Address - Country:US
Mailing Address - Phone:210-227-9376
Mailing Address - Fax:210-227-0916
Practice Address - Street 1:1303 MCCULLOUGH AVE
Practice Address - Street 2:SUITE 561
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-5668
Practice Address - Country:US
Practice Address - Phone:210-227-9376
Practice Address - Fax:210-227-0916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX083200801Medicaid
TXCP8906OtherRAILROAD MEDICARE
TX00J538Medicare ID - Type Unspecified