Basic Information
| Provider Information | |||||||||
| NPI: | 1912571795 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UROLOGY ASC - PHOENIX, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 CROSSROADS DR STE 306 | ||||||||
| Address2: | |||||||||
| City: | OWINGS MILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211175437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669533111 | ||||||||
| FaxNumber: | 4434718540 | ||||||||
| Practice Location | |||||||||
| Address1: | 16390 N 59TH AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853061711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022415105 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2021 | ||||||||
| LastUpdateDate: | 05/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | SIEGEL | ||||||||
| AuthorizedOfficialFirstName: | SANFORD | ||||||||
| AuthorizedOfficialMiddleName: | JAY | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4105811600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.