MEDICARE: MASS BAY UROLOGIC ASSOC

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	57617	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	M16068	OTHER	MA	BC/BS MA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730189341
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MASS BAY UROLOGIC ASSOC

Provider Business Mailing Address
First Line	:	72 SHARP ST
Second Line	:
City	:	HINGHAM
State	:	MA
Zip	:	02043-4351
Country	:	US
Telephone Number	:	781-337-0201
Fax Number	:	781-335-3674

Provider Business Practice Location Address
First Line	:	2100 DORCHESTER AVE
Second Line	:	SUITE 2206
City	:	DORCHESTER CENTER
State	:	MA
Zip	:	02124-5615
Country	:	US
Telephone Number	:	617-296-2222
Fax Number	:	617-296-3834

Authorized Official
Title or Position	:	OWNER
Name	:	CLIFFORD D GLUCK
Credential	:	M.D.
Telephone Number	:	617-296-2222

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	09/24/2010

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Directions to “MASS BAY UROLOGIC ASSOC ” Practice Location

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