Provider Demographics
NPI:1093138067
Name:AGUADA INTERNAL MEDICINE SERVICE PSC
Entity Type:Organization
Organization Name:AGUADA INTERNAL MEDICINE SERVICE PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:ROBERTO
Authorized Official - Last Name:SOTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-431-9470
Mailing Address - Street 1:PO BOX 873
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602-0873
Mailing Address - Country:US
Mailing Address - Phone:787-868-8200
Mailing Address - Fax:787-868-8200
Practice Address - Street 1:230 CALLE MARINA
Practice Address - Street 2:
Practice Address - City:AGUADA
Practice Address - State:PR
Practice Address - Zip Code:00602-3217
Practice Address - Country:US
Practice Address - Phone:787-868-8200
Practice Address - Fax:787-868-8200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-28
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16689302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR25247Medicare UPIN