MEDICARE: WATERSHED UROLOGY, P.C.

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	MD050185L	PA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DB4793	OTHER	PA	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1467578732
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WATERSHED UROLOGY, P.C.

Provider Business Mailing Address
First Line	:	9 BROOKWOOD AVE
Second Line	:
City	:	CARLISLE
State	:	PA
Zip	:	17015-9126
Country	:	US
Telephone Number	:	717-241-2200
Fax Number	:	717-245-9611

Provider Business Practice Location Address
First Line	:	9 BROOKWOOD AVE
Second Line	:
City	:	CARLISLE
State	:	PA
Zip	:	17015-9126
Country	:	US
Telephone Number	:	717-241-2200
Fax Number	:	717-245-9611

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. BRUCE V. GRONKIEWICZ
Credential	:	M.D.
Telephone Number	:	717-241-2200

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	01/15/2008

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