Provider Demographics
NPI:1275606071
Name:COLON AND RECTAL SURGICAL GROUP OF PUERTO RICO PSC
Entity Type:Organization
Organization Name:COLON AND RECTAL SURGICAL GROUP OF PUERTO RICO PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SANTIAGO
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:ULLOA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-707-0095
Mailing Address - Street 1:PO BOX 19060
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00910-1060
Mailing Address - Country:US
Mailing Address - Phone:787-707-0095
Mailing Address - Fax:787-707-0096
Practice Address - Street 1:107 GONZALEZ GUISTI AVE
Practice Address - Street 2:CAPARRA GALLERY BLDG SUITE 305
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00966-3017
Practice Address - Country:US
Practice Address - Phone:787-707-0095
Practice Address - Fax:787-707-0096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10722208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0021481Medicare PIN