Provider Demographics
NPI:1316989635
Name:EL CAMINO UROLOGY MEDICAL GROUP, INC
Entity type:Organization
Organization Name:EL CAMINO UROLOGY MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-962-4662
Mailing Address - Street 1:2490 HOSPITAL DR.
Mailing Address - Street 2:STE. 210
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-4323
Mailing Address - Country:US
Mailing Address - Phone:650-962-4662
Mailing Address - Fax:650-962-4652
Practice Address - Street 1:2490 HOSPITAL DR.
Practice Address - Street 2:STE. 210
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-4323
Practice Address - Country:US
Practice Address - Phone:650-962-4662
Practice Address - Fax:650-962-4652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ47841ZMedicare ID - Type Unspecified