Basic Information
| Provider Information | |||||||||
| NPI: | 1770516908 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDRENS UROLOGY ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 SW 60TH CT | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331554000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056696448 | ||||||||
| FaxNumber: | 3056638485 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 SW 60TH CT | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331554000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056696448 | ||||||||
| FaxNumber: | 3056638485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 05/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | MOY | ||||||||
| AuthorizedOfficialFirstName: | EDDA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3056696448 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 38599 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 255861100 | 05 | FL | MEDICAID |