Basic Information
Provider Information | |||||||||
NPI: | 1528109006 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ASSOCIATED UROLOGICAL SPECIALISTS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SPECIALIZED UROLOGICAL CONSULTANTS-ORLAND PARK | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10400 SOUTHWEST HWY | ||||||||
Address2: | LOWER LEVEL | ||||||||
City: | CHICAGO RIDGE | ||||||||
State: | IL | ||||||||
PostalCode: | 604151367 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7085817308 | ||||||||
FaxNumber: | 7082744027 | ||||||||
Practice Location | |||||||||
Address1: | 16632 107TH ST | ||||||||
Address2: |   | ||||||||
City: | ORLAND PARK | ||||||||
State: | IL | ||||||||
PostalCode: | 604678898 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7083496350 | ||||||||
FaxNumber: | 7083499153 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/09/2007 | ||||||||
LastUpdateDate: | 03/18/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROQUE | ||||||||
AuthorizedOfficialFirstName: | ELIZA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 7086082195 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/18/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2088P0231X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | 208800000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |   |
No ID Information.