Provider Demographics
NPI:1043595291
Name:MD RENAL GROUP LLC
Entity Type:Organization
Organization Name:MD RENAL GROUP LLC
Other - Org Name:MD RENAL GROUP LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATIVE CHIEF OFFICER
Authorized Official - Prefix:PROF
Authorized Official - First Name:MAYRA
Authorized Official - Middle Name:I
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:939-639-0557
Mailing Address - Street 1:PO BOX 667
Mailing Address - Street 2:
Mailing Address - City:MOCA
Mailing Address - State:PR
Mailing Address - Zip Code:00676-0667
Mailing Address - Country:US
Mailing Address - Phone:787-997-0101
Mailing Address - Fax:
Practice Address - Street 1:AVENUE SEVERIANO CUEVAS 18
Practice Address - Street 2:HOSPITAL BUEN SAMARITANO GROUND FLOOR
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00605-9026
Practice Address - Country:US
Practice Address - Phone:787-997-0101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17129302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1043595291OtherNPI