Basic Information
| Provider Information | |||||||||
| NPI: | 1508815754 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BEND UROLOGY ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2090 NE WYATT CT | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977017687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413826447 | ||||||||
| FaxNumber: | 5413307413 | ||||||||
| Practice Location | |||||||||
| Address1: | 2090 NE WYATT CT | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977017687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413826447 | ||||||||
| FaxNumber: | 5413307413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JORDAN | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | GENE | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5413826447 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.