=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982976056
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREDERICK UROLOGY ASSOCIATES PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2012
-----------------------------------------------------
Last Update Date | 02/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 BAUGHMANS LN
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21702-4059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-694-8080
-----------------------------------------------------
Fax | 301-694-8089
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 BAUGHMANS LN
-----------------------------------------------------
City | FREDERICK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21702-4059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-694-8080
-----------------------------------------------------
Fax | 301-694-8089
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MOHAMMED M MOHIUDDIN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 301-694-8080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | D0020015
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------