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General NPI Number Information
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NPI Number | 1730189341
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Entity Type | Organization
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Legal Business Name | MASS BAY UROLOGIC ASSOC
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Dates
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Enumeration Date | 07/26/2005
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Last Update Date | 09/24/2010
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Provider Practice Location Address
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Address Line | 2100 DORCHESTER AVE SUITE 2206
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City | DORCHESTER CENTER
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State | MA
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Zip | 02124-5615
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Country | US
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Telephone | 617-296-2222
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Fax | 617-296-3834
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Provider Business Mailing Address
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Address Line | 72 SHARP ST
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City | HINGHAM
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State | MA
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Zip | 02043-4351
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Country | US
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Telephone | 781-337-0201
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Fax | 781-335-3674
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Authorized Official
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Title or Position | OWNER
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Name | CLIFFORD D GLUCK
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Credential | M.D.
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Telephone | 617-296-2222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 57617
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License Number State | MA
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