MEDICARE: UROLOGY DYNAMIC, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician	152821	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558492314
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UROLOGY DYNAMIC, PC

Provider Business Mailing Address
First Line	:	7603 113TH ST
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-6530
Country	:	US
Telephone Number	:	718-204-0414
Fax Number	:	718-204-7470

Provider Business Practice Location Address
First Line	:	7603 113TH ST
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-6530
Country	:	US
Telephone Number	:	718-204-0414
Fax Number	:	718-204-7470

Authorized Official
Title or Position	:	PRESIDENT
Name	:	AYAZ RASOOL
Credential	:	MD
Telephone Number	:	718-268-7262

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	12/02/2011

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