Healthcare Provider Details

I. General information

NPI: 1710813233
Provider Name (Legal Business Name): ELEVATE UROLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 HEBRON AVE STE 10
GLASTONBURY CT
06033-5016
US

IV. Provider business mailing address

730 HEBRON AVE STE 10
GLASTONBURY CT
06033-5016
US

V. Phone/Fax

Practice location:
  • Phone: 860-266-5550
  • Fax: 860-266-5511
Mailing address:
  • Phone: 860-266-5550
  • Fax: 860-266-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SHANTA SHEPHERD
Title or Position: OWNER
Credential: MD
Phone: 860-266-5550