Provider Demographics
NPI:1235458290
Name:CARDIOVASCULAR SURGERY OF PR PSC
Entity Type:Organization
Organization Name:CARDIOVASCULAR SURGERY OF PR PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-773-0417
Mailing Address - Street 1:735 AVE PONCE DE LEON SUITE 210
Mailing Address - Street 2:TORRE MEDICA AUXILIO MUTUO
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00917-5024
Mailing Address - Country:US
Mailing Address - Phone:787-773-0417
Mailing Address - Fax:
Practice Address - Street 1:735 AVE PONCE DE LEON SUITE 210
Practice Address - Street 2:TORRE MEDICA AUXILIO MUTUO
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917-5024
Practice Address - Country:US
Practice Address - Phone:787-773-0417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-28
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR88802086S0129X, 208G00000X
PR16635208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRF86890Medicare UPIN