Provider Demographics
NPI:1104955798
Name:MONTCLAIR UROLOGICAL GROUP
Entity type:Organization
Organization Name:MONTCLAIR UROLOGICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOORJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-746-3322
Mailing Address - Street 1:777 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07028-2325
Mailing Address - Country:US
Mailing Address - Phone:973-746-3322
Mailing Address - Fax:973-429-8765
Practice Address - Street 1:777 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:GLEN RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07028-2325
Practice Address - Country:US
Practice Address - Phone:973-746-3322
Practice Address - Fax:973-429-8765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA26559174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJH14434Medicare UPIN
NJ182806Medicare ID - Type Unspecified
NJD97079Medicare UPIN
NJC53473Medicare UPIN
NJH92048Medicare UPIN
NJ081042AVSMedicare ID - Type Unspecified
NJ135045AVSMedicare ID - Type Unspecified
NJ096206AVSMedicare ID - Type Unspecified
NJ037320AVSMedicare ID - Type Unspecified