Provider Demographics
NPI:1538419833
Name:PEDIATRIC AND ADOLESCENT UROLOGY INSTITUTE
Entity type:Organization
Organization Name:PEDIATRIC AND ADOLESCENT UROLOGY INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-292-2111
Mailing Address - Street 1:14100 CEDAR ROAD
Mailing Address - Street 2:SUITE 280
Mailing Address - City:UNIVERSITY HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44121
Mailing Address - Country:US
Mailing Address - Phone:216-292-2111
Mailing Address - Fax:
Practice Address - Street 1:14100 CEDAR ROAD
Practice Address - Street 2:SUITE 280
Practice Address - City:UNIVERSITY HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44121
Practice Address - Country:US
Practice Address - Phone:216-292-2111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35080080208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty