Basic Information
| Provider Information | |||||||||
| NPI: | 1164421467 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAMBRIDGE UROLOGICAL ASSOCIATES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 MAIN ST | ||||||||
| Address2: | STE 670 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087543566 | ||||||||
| FaxNumber: | 5084386368 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 MOUNT AUBURN ST | ||||||||
| Address2: | STE 519 | ||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021385600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175474400 | ||||||||
| FaxNumber: | 6175761076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | CROCKER | ||||||||
| AuthorizedOfficialFirstName: | RODERICK | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6175474400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 9701974 | 05 | MA | MEDICAID |