Provider Demographics
NPI:1124435664
Name:CHESTERFIELD UROLOGY, LLC
Entity type:Organization
Organization Name:CHESTERFIELD UROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:ROBERTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-381-7448
Mailing Address - Street 1:16901 BLAKEWAY PL
Mailing Address - Street 2:
Mailing Address - City:MOSELEY
Mailing Address - State:VA
Mailing Address - Zip Code:23120-1369
Mailing Address - Country:US
Mailing Address - Phone:804-381-7448
Mailing Address - Fax:
Practice Address - Street 1:16901 BLAKEWAY PL
Practice Address - Street 2:
Practice Address - City:MOSELEY
Practice Address - State:VA
Practice Address - Zip Code:23120-1369
Practice Address - Country:US
Practice Address - Phone:804-381-7448
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057462208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty