=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598309791
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIGNATURE UROLOGY SPECIALISTS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2019
-----------------------------------------------------
Last Update Date | 08/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1127 WILSHIRE BLVD STE 805
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90017-3909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-212-4314
-----------------------------------------------------
Fax | 213-212-4366
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1127 WILSHIRE BLVD STE 805
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90017-3909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-212-4314
-----------------------------------------------------
Fax | 213-212-4366
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOOK KEEPER
-----------------------------------------------------
Name | MR. JAMES E ROTH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 213-212-4314
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------