1174618631 NPI number — ANESTHESIA MEDICAL GROUP PSCORP

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 1174618631 NPI number — ANESTHESIA MEDICAL GROUP PSCORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANESTHESIA MEDICAL GROUP PSCORP
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:
1174618631
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8024 CALLE CONCORDIA STE 405
Provider Second Line Business Mailing Address:
URB. SANTA MARIA
Provider Business Mailing Address City Name:
PONCE
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00717-1510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-812-3318
Provider Business Mailing Address Fax Number:
787-290-3318

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8024 CALLE CONCORDIA STE 405
Provider Second Line Business Practice Location Address:
URB. SANTA MARIA
Provider Business Practice Location Address City Name:
PONCE
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00717-1510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-812-3318
Provider Business Practice Location Address Fax Number:
787-290-3318
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SANTOS BELLO
Authorized Official First Name:
MIGUEL
Authorized Official Middle Name:
ENRIQUE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
787-812-3318

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  10892 , 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)

  • Identifier: 037440300 , issued by the state of ( PR ) . This identifiers is of the category "MEDICAID".




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