=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154403418
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UROLOGIC SPECIALTIES PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2006
-----------------------------------------------------
Last Update Date | 09/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 177 NORTH DEAN ST SUITE 305
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-569-7777
-----------------------------------------------------
Fax | 201-569-6861
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 177 NORTH DEAN ST SUITE 305
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-569-7777
-----------------------------------------------------
Fax | 201-569-6861
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MRS. MICHELE M. RASMUSSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 201-569-7777
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------