1780633651 NPI number — SOUTHERN INTERNAL MEDICINE GROUP, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780633651 NPI number — SOUTHERN INTERNAL MEDICINE GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN INTERNAL MEDICINE GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHERN INTERNAL MEDICINE GROUP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780633651
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7819
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PONCE
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00732-7819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-844-1248
Provider Business Mailing Address Fax Number:
787-290-0706

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2225 PONCE BYE PASS STE 302
Provider Second Line Business Practice Location Address:
EDIFICIO PARRA
Provider Business Practice Location Address City Name:
PONCE
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00717-1322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-844-1248
Provider Business Practice Location Address Fax Number:
787-290-0706
Provider Enumeration Date:
05/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BENITEZ LORENZO
Authorized Official First Name:
PEDRO
Authorized Official Middle Name:
LUIS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
787-844-1248

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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