Provider Demographics
NPI:1871822072
Name:ROSEVILLE UROLOGY, INC.
Entity type:Organization
Organization Name:ROSEVILLE UROLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:COUILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-768-3290
Mailing Address - Street 1:7936 INDIAN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:ORANGEVALE
Mailing Address - State:CA
Mailing Address - Zip Code:95662
Mailing Address - Country:US
Mailing Address - Phone:916-768-3290
Mailing Address - Fax:
Practice Address - Street 1:5 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE 250
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2865
Practice Address - Country:US
Practice Address - Phone:916-782-2229
Practice Address - Fax:916-797-9414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-17
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68651208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G68651Medicare PIN
CAF38442Medicare UPIN