Provider Demographics
NPI:1306987896
Name:ASSOCIATED UROLOGICAL SPECIALISTS LLC
Entity type:Organization
Organization Name:ASSOCIATED UROLOGICAL SPECIALISTS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-608-2195
Mailing Address - Street 1:10400 SOUTHEST HIGHWAY
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415
Mailing Address - Country:US
Mailing Address - Phone:708-581-7308
Mailing Address - Fax:
Practice Address - Street 1:2850 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2735
Practice Address - Country:US
Practice Address - Phone:708-422-2242
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C41893Medicare UPIN
211475Medicare PIN
5433040009Medicare NSC
G88948Medicare UPIN
G14922Medicare UPIN