Basic Information
| Provider Information | |||||||||
| NPI: | 1043495328 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VALLEY UROLOGISTS, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 MAIN ST | ||||||||
| Address2: | STE. 670 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087543566 | ||||||||
| FaxNumber: | 5087988021 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 DUNNING ST | ||||||||
| Address2: | |||||||||
| City: | CLAREMONT | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037432070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035427669 | ||||||||
| FaxNumber: | 6035431323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2008 | ||||||||
| LastUpdateDate: | 11/11/2009 | ||||||||
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| AuthorizedOfficialLastName: | CRICCO | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | PHILIP | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 6035427669 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 6007 | NH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 82346864 | 05 | NH | MEDICAID |