Basic Information
| Provider Information | |||||||||
| NPI: | 1851515993 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEASTERN OHIO UROLOGICAL SURGEONS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 885 S SAWBURG RD | ||||||||
| Address2: | |||||||||
| City: | ALLIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446015905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308231112 | ||||||||
| FaxNumber: | 3308231139 | ||||||||
| Practice Location | |||||||||
| Address1: | 885 S SAWBURG RD | ||||||||
| Address2: | |||||||||
| City: | ALLIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446015905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308231112 | ||||||||
| FaxNumber: | 3308231139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 06/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | BLACK | ||||||||
| AuthorizedOfficialFirstName: | BRADFORD | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3308231112 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 35058282 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | CN7807 | 01 | OH | RAILROAD MEDICARE GROUP NUMBER | OTHER |