MEDICARE: ADVANCED SURGICAL UROLOGY PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician	211186	NY

General Provider Information

NPI Number	:	1447410881
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED SURGICAL UROLOGY PC

Provider Business Mailing Address
First Line	:	1900 QUENTIN RD
Second Line	:	APT A22
City	:	BROOKLYN
State	:	NY
Zip	:	11229-2369
Country	:	US
Telephone Number	:	718-646-0909
Fax Number	:	718-646-8688

Provider Business Practice Location Address
First Line	:	2844 OCEAN PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-7900
Country	:	US
Telephone Number	:	718-646-0909
Fax Number	:	718-646-8688

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ALEXANDER Y MARIBAKH
Credential	:
Telephone Number	:	718-646-0909

Provider Enumeration Date	:	06/10/2008
Last Update Date	:	06/10/2008

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