Provider Demographics
NPI:1114050879
Name:INTERNAL MEDICINE PROFESSIONAL SERVICES, PSC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE PROFESSIONAL SERVICES, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:SEPULVEDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-633-3615
Mailing Address - Street 1:PO BOX 10714
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00922-0714
Mailing Address - Country:US
Mailing Address - Phone:787-633-3615
Mailing Address - Fax:
Practice Address - Street 1:400 AVE DOMENECH STE 408
Practice Address - Street 2:LAS AMERICAS PROFESSIONAL CENTER
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3706
Practice Address - Country:US
Practice Address - Phone:787-633-3615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10015261QC1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRF-28754Medicare UPIN
PR8-2653Medicare ID - Type Unspecified