Provider Demographics
NPI:1043412752
Name:SAN JORGE CHILDREN'S MEDICAL SPECIALTIES,PSC
Entity Type:Organization
Organization Name:SAN JORGE CHILDREN'S MEDICAL SPECIALTIES,PSC
Other - Org Name:SAN JORGE CHILDREN'S MEDICAL SPECIALTIES AMB. SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLAVELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-728-1575
Mailing Address - Street 1:252 SAN JORGE AVE.SAN JORGE MEDICAL BLDG
Mailing Address - Street 2:SAN JORGE MEDICAL BLDG SUITE 504
Mailing Address - City:SANTURCE
Mailing Address - State:PR
Mailing Address - Zip Code:00912-3310
Mailing Address - Country:US
Mailing Address - Phone:787-728-1575
Mailing Address - Fax:
Practice Address - Street 1:252 SAN JORGE AVE.SAN JORGE MEDICAL BLDG
Practice Address - Street 2:SAN JORGE MEDICAL BLDG SUITE 504
Practice Address - City:SANTURCE
Practice Address - State:PR
Practice Address - Zip Code:00912
Practice Address - Country:US
Practice Address - Phone:787-728-1575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN JORGE CHILDRENS' MEDICAL SPECIALTIES, PSC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-04
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5762174400000X
PR05-B-1068261QX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR12501OtherTRIPLE S
PR20062OtherTRIPLE S