Provider Demographics
NPI:1730189341
Name:MASS BAY UROLOGIC ASSOC
Entity type:Organization
Organization Name:MASS BAY UROLOGIC ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:D
Authorized Official - Last Name:GLUCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-296-2222
Mailing Address - Street 1:72 SHARP ST
Mailing Address - Street 2:
Mailing Address - City:HINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02043-4351
Mailing Address - Country:US
Mailing Address - Phone:781-337-0201
Mailing Address - Fax:781-335-3674
Practice Address - Street 1:2100 DORCHESTER AVE
Practice Address - Street 2:SUITE 2206
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-5615
Practice Address - Country:US
Practice Address - Phone:617-296-2222
Practice Address - Fax:617-296-3834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA57617208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM16068OtherBC/BS MA
MA9774106Medicaid
MAM16068OtherBC/BS MA