Healthcare Provider Details

I. General information

NPI: 1528109006
Provider Name (Legal Business Name): ASSOCIATED UROLOGICAL SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16632 107TH ST
ORLAND PARK IL
60467-8898
US

IV. Provider business mailing address

10400 SOUTHWEST HWY LOWER LEVEL
CHICAGO RIDGE IL
60415-1367
US

V. Phone/Fax

Practice location:
  • Phone: 708-349-6350
  • Fax: 708-349-9153
Mailing address:
  • Phone: 708-581-7308
  • Fax: 708-274-4027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number
License Number State

VIII. Authorized Official

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