Provider Demographics
NPI:1194755033
Name:ADULT UROLOGY CLINIC PA
Entity type:Organization
Organization Name:ADULT UROLOGY CLINIC PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUANN
Authorized Official - Middle Name:
Authorized Official - Last Name:WIITA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-747-5885
Mailing Address - Street 1:1002 OLD DIXIE HWY.
Mailing Address - Street 2:SUITE 104
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-5700
Mailing Address - Country:US
Mailing Address - Phone:561-747-5885
Mailing Address - Fax:561-743-5456
Practice Address - Street 1:1002 OLD DIXIE HWY.
Practice Address - Street 2:SUITE 104
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-5700
Practice Address - Country:US
Practice Address - Phone:561-747-5885
Practice Address - Fax:561-743-5456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0014196208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL97958Medicare ID - Type Unspecified