1104895002 NPI number — INSTITUTO CARDIOVASCULAR SAN RAFAEL

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 1104895002 NPI number — INSTITUTO CARDIOVASCULAR SAN RAFAEL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INSTITUTO CARDIOVASCULAR SAN RAFAEL
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:
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:
1104895002
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1396 CALLE SAN RAFAEL
Provider Second Line Business Mailing Address:
CONDOMINIO MEDICAL PAVILION SUITE 17
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00909-2526
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-722-2992
Provider Business Mailing Address Fax Number:
787-724-2710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1396 CALLE SAN RAFAEL
Provider Second Line Business Practice Location Address:
CONDOMINIO MEDICAL PAVILION SUITE 17
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00909-2526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-722-2992
Provider Business Practice Location Address Fax Number:
787-724-2710
Provider Enumeration Date:
03/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DEVARIE
Authorized Official First Name:
MARCOS
Authorized Official Middle Name:
Authorized Official Title or Position:
CO-DIRECTOR
Authorized Official Telephone Number:
787-722-2992

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  5544 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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