Healthcare Provider Details

I. General information

NPI: 1497700363
Provider Name (Legal Business Name): PHILADELPHIA UROLOGY ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 08/31/2021
Certification Date: 06/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 CHESTNUT ST STE 405
PHILADELPHIA PA
19107-4304
US

IV. Provider business mailing address

1015 CHESTNUT ST STE 405
PHILADELPHIA PA
19107-4304
US

V. Phone/Fax

Practice location:
  • Phone: 215-563-1199
  • Fax: 215-563-1783
Mailing address:
  • Phone: 215-563-1199
  • Fax: 215-563-1783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ETHEL ROSENBERG
Title or Position: OFFICE MANAGER
Credential:
Phone: 215-563-1199