Provider Demographics
NPI:1164846879
Name:MALAVE SURGICAL GROUP,PSC
Entity Type:Organization
Organization Name:MALAVE SURGICAL GROUP,PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:MALAVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-600-4404
Mailing Address - Street 1:MANSIONES DE LOS ARTESANOS #14
Mailing Address - Street 2:
Mailing Address - City:LAS PIEDRAS
Mailing Address - State:PR
Mailing Address - Zip Code:00771
Mailing Address - Country:US
Mailing Address - Phone:787-600-4404
Mailing Address - Fax:
Practice Address - Street 1:CARRETERA ESTATAL #3 KM 78.4
Practice Address - Street 2:PARCELA 3 BO. RIO ABAJO
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791
Practice Address - Country:US
Practice Address - Phone:787-600-4404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-17
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15768207RG0100X, 207RI0008X
PR16315208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0026258OtherMEDICARE PTAN
PREC729AOtherMEDICARE PTAN