1710030457 NPI number — ADULT AND PEDIATRIC UROLOGY CENTER

Table of content: MISS DOMINIKA DAGMARA MITERA (NPI 1538837828)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710030457 NPI number — ADULT AND PEDIATRIC UROLOGY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADULT AND PEDIATRIC UROLOGY CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710030457
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
966 PARK ST # B
Provider Second Line Business Mailing Address:
SUITE B3
Provider Business Mailing Address City Name:
STOUGHTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02072-3650
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-344-3506
Provider Business Mailing Address Fax Number:
781-341-4065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
966 PARK ST # B
Provider Second Line Business Practice Location Address:
SUITE B3
Provider Business Practice Location Address City Name:
STOUGHTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02072-3650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-344-3506
Provider Business Practice Location Address Fax Number:
781-341-4065
Provider Enumeration Date:
01/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SINGH
Authorized Official First Name:
REKHA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
781-344-3506

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9787704 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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