Provider Demographics
NPI:1033261862
Name:SOUTHERN GASTROENTEROLOGY MEDICAL GROUP, PSC
Entity Type:Organization
Organization Name:SOUTHERN GASTROENTEROLOGY MEDICAL GROUP, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ARNALDO
Authorized Official - Middle Name:M
Authorized Official - Last Name:NIEVES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-843-0348
Mailing Address - Street 1:PO BOX 7183
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00732-7183
Mailing Address - Country:US
Mailing Address - Phone:787-843-0348
Mailing Address - Fax:787-840-8623
Practice Address - Street 1:7810 CALLE NAZARET
Practice Address - Street 2:URB SANTA MARIA
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1008
Practice Address - Country:US
Practice Address - Phone:787-843-0348
Practice Address - Fax:787-840-8623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12225174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty