Provider Demographics
NPI:1366612434
Name:UROLOGIC SURGICAL CARE PLLC
Entity type:Organization
Organization Name:UROLOGIC SURGICAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:A
Authorized Official - Last Name:GROTAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-239-8585
Mailing Address - Street 1:290 CENTRAL AVENUE
Mailing Address - Street 2:#207
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-8507
Mailing Address - Country:US
Mailing Address - Phone:516-239-8585
Mailing Address - Fax:
Practice Address - Street 1:290 CENTRAL AVENUE
Practice Address - Street 2:#207
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-8507
Practice Address - Country:US
Practice Address - Phone:516-239-8585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235437208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02663321Medicaid
NYI40411Medicare UPIN
NY02663321Medicaid