Provider Demographics
NPI:1164494928
Name:CENTRO MEDICO RUIZ-MONTERO PC
Entity Type:Organization
Organization Name:CENTRO MEDICO RUIZ-MONTERO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ-MONTERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-397-8965
Mailing Address - Street 1:4320 FIR ST
Mailing Address - Street 2:STE 410
Mailing Address - City:EAST CHICAGO
Mailing Address - State:IN
Mailing Address - Zip Code:46312-3052
Mailing Address - Country:US
Mailing Address - Phone:219-397-8965
Mailing Address - Fax:219-397-9351
Practice Address - Street 1:4320 FIR ST
Practice Address - Street 2:STE 410
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-3052
Practice Address - Country:US
Practice Address - Phone:219-397-8965
Practice Address - Fax:219-397-9351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052348207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200287720BMedicaid
IN110241554OtherMEDICARE RAILROAD
IN200287720BMedicaid