Provider Demographics
NPI:1972711950
Name:SOUTH BAY UROLOGIC ASSOCIATES, P.C.
Entity type:Organization
Organization Name:SOUTH BAY UROLOGIC ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:BERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-587-5444
Mailing Address - Street 1:747 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4911
Mailing Address - Country:US
Mailing Address - Phone:631-587-5444
Mailing Address - Fax:631-587-4938
Practice Address - Street 1:747 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4911
Practice Address - Country:US
Practice Address - Phone:631-587-5444
Practice Address - Fax:631-587-4938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
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
NYW33871Medicare ID - Type Unspecified