Provider Demographics
NPI:1366626996
Name:SUBURBAN UROLOGY ASSOCIATES,LTD
Entity type:Organization
Organization Name:SUBURBAN UROLOGY ASSOCIATES,LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:MISUREC
Authorized Official - Suffix:
Authorized Official - Credentials:M,D
Authorized Official - Phone:708-484-6019
Mailing Address - Street 1:3340 OAK PARK AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3420
Mailing Address - Country:US
Mailing Address - Phone:708-484-6019
Mailing Address - Fax:708-484-0251
Practice Address - Street 1:3340 OAK PARK AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3420
Practice Address - Country:US
Practice Address - Phone:708-484-6019
Practice Address - Fax:708-484-0251
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUBURBAN UROLOGY ASSOCIATES,LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-18
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36061571174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty