Provider Demographics
NPI:1194725978
Name:CHESTNUT UROLOGY PC
Entity type:Organization
Organization Name:CHESTNUT UROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MERINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-449-0646
Mailing Address - Street 1:340 MAIN ST
Mailing Address - Street 2:STE 670
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1604
Mailing Address - Country:US
Mailing Address - Phone:508-754-3566
Mailing Address - Fax:508-798-8012
Practice Address - Street 1:87 CHESTNUT ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492
Practice Address - Country:US
Practice Address - Phone:781-449-0646
Practice Address - Fax:781-455-9262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9761772Medicaid
MA9761772Medicaid