1053945022 NPI number — DR SUSONI HEALTH COMMUNITY SERVICES CORP

Table of content: (NPI 1053945022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053945022 NPI number — DR SUSONI HEALTH COMMUNITY SERVICES CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR SUSONI HEALTH COMMUNITY SERVICES CORP
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:
Provider Other Organization Name Type Code:
6
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:
1053945022
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 659
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARECIBO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00613-0659
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-650-7272
Provider Business Mailing Address Fax Number:
787-650-7310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CARR, 129 KM 1.0
Provider Second Line Business Practice Location Address:
AVE SAN LUIS
Provider Business Practice Location Address City Name:
ARECIBO
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00613-0659
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-650-7272
Provider Business Practice Location Address Fax Number:
787-650-7310
Provider Enumeration Date:
02/27/2020

Additional Information

Authorized Official

Authorized Official Last Name:
MEDINA
Authorized Official First Name:
JUAN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
BILLING AND COLLECTIONS DIRECTOR
Authorized Official Telephone Number:
787-650-7272

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 400087 , issued by the state of ( PR ) . This identifiers is of the category "MEDICAID".




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