Basic Information
| Provider Information | |||||||||
| NPI: | 1255352423 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY UROGYNECOLOGY ASSOCIATION, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 FEDERAL STREET | ||||||||
| Address2: | SW-200 | ||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563564924 | ||||||||
| FaxNumber: | 8563826455 | ||||||||
| Practice Location | |||||||||
| Address1: | 6012 MAIN STREET | ||||||||
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| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080434659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563256622 | ||||||||
| FaxNumber: | 8563256652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 07/28/2016 | ||||||||
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| AuthorizedOfficialLastName: | MAZZARELLI | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICE | ||||||||
| AuthorizedOfficialTelephone: | 8569687858 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 2086S0122X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | 207V00000X | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 8200301 | 05 | NJ | MEDICAID |