MEDICARE: THE ADULT & PEDIATRIC UROLOGY GRP OF MD

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		MD

General Provider Information

NPI Number	:	1639370273
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE ADULT & PEDIATRIC UROLOGY GRP OF MD

Provider Business Mailing Address
First Line	:	9055 CHEVROLET DR
Second Line	:	SUITE 201
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-4016
Country	:	US
Telephone Number	:	410-465-7533
Fax Number	:

Provider Business Practice Location Address
First Line	:	9055 CHEVROLET DR
Second Line	:	SUITE 201
City	:	ELLICOTT CITY
State	:	MD
Zip	:	21042-4016
Country	:	US
Telephone Number	:	410-465-7533
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	BRIDGET MASTROUNNI
Credential	:
Telephone Number	:	410-646-0330

Provider Enumeration Date	:	05/30/2007
Last Update Date	:	08/22/2020

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