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General NPI Number Information
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NPI Number | 1366626996
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Entity Type | Organization
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Legal Business Name | SUBURBAN UROLOGY ASSOCIATES,LTD
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Dates
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Enumeration Date | 12/18/2007
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Last Update Date | 12/14/2010
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Provider Practice Location Address
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Address Line | 3340 OAK PARK AVE SUITE 305
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City | BERWYN
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State | IL
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Zip | 60402-3420
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Country | US
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Telephone | 708-484-6019
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Fax | 708-484-0251
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Provider Business Mailing Address
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Address Line | 3340 OAK PARK AVE SUITE 305
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City | BERWYN
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State | IL
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Zip | 60402-3420
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Country | US
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Telephone | 708-484-6019
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Fax | 708-484-0251
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. PETER MISUREC
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Credential | M,D.
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Telephone | 708-484-6019
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 36061571
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License Number State | IL
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