Basic Information
| Provider Information | |||||||||
| NPI: | 1194721530 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AFFILIATED UROLOGISTS, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 W THOMAS RD | ||||||||
| Address2: | STE 600 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022640608 | ||||||||
| FaxNumber: | 6022340417 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W THOMAS RD | ||||||||
| Address2: | STE 600 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850134221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022640608 | ||||||||
| FaxNumber: | 6022340417 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PONAS | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | HENRY | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6022640608 | ||||||||
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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 | 208800000X | 22477 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 507048 | 05 | AZ | MEDICAID |