1649625013 NPI number — SOUTHERN INTERNAL MEDICINE INSTITUTE

Table of content: (NPI 1649625013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649625013 NPI number — SOUTHERN INTERNAL MEDICINE INSTITUTE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN INTERNAL MEDICINE INSTITUTE
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:
1649625013
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
609 AVE TITO CASTRO
Provider Second Line Business Mailing Address:
STE 102 PMB 153
Provider Business Mailing Address City Name:
PONCE
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00716
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-259-3316
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
609 AVE TITO CASTRO
Provider Second Line Business Practice Location Address:
STE 102 PMB 153
Provider Business Practice Location Address City Name:
PONCE
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00716-0200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-259-3316
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/04/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MATOS FIGUEROA
Authorized Official First Name:
JORGE
Authorized Official Middle Name:
RUBEN
Authorized Official Title or Position:
PYSICIAN
Authorized Official Telephone Number:
787-259-3316

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  11526 , 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: 11526 . This is a "INTERNAL MEDICINE" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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