Basic Information
| Provider Information | |||||||||
| NPI: | 1558399568 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENINSULA UROLOGY CENTER INC | ||||||||
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| OtherOrganizationName: | CHRIS THREATT, MD, INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 WHIPPLE AVE | ||||||||
| Address2: | SUITE 132 | ||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940622843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503061016 | ||||||||
| FaxNumber: | 6503693627 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 WHIPPLE AVE | ||||||||
| Address2: | SUITE 132 | ||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940622843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6503061016 | ||||||||
| FaxNumber: | 6503693627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 06/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | THREATT | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6503061016 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | A79072 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.