Healthcare Provider Details

I. General information

NPI: 1093055170
Provider Name (Legal Business Name): ALPHA UROLOGY GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2013
Last Update Date: 02/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4244 RIVERWALK PKWY SUITE 240
RIVERSIDE CA
92505-8509
US

IV. Provider business mailing address

4244 RIVERWALK PKWY SUITE 240
RIVERSIDE CA
92505-8509
US

V. Phone/Fax

Practice location:
  • Phone: 951-509-3580
  • Fax: 951-509-4552
Mailing address:
  • Phone: 951-509-3580
  • Fax: 951-509-4552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: ERIC L SHEPARD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 951-509-3580