Healthcare Provider Details

I. General information

NPI: 1710126032
Provider Name (Legal Business Name): ASSOCIATED UROLOGICAL SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2009
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10400 SOUTHWEST HWY
CHICAGO RIDGE IL
60415-1367
US

IV. Provider business mailing address

16522 106TH CT
ORLAND PARK IL
60467-4547
US

V. Phone/Fax

Practice location:
  • Phone: 708-581-7308
  • Fax: 708-274-4027
Mailing address:
  • Phone: 708-590-8770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036-102534
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number036-062338
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036-094573
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036-257763
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036-096031
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number036-076990
License Number StateIL
# 7
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036-120732
License Number StateIL

VIII. Authorized Official

Name: ELIZA ROQUE
Title or Position: DIRECTOR
Credential:
Phone: 708-608-2195