Provider Demographics
NPI:1295020790
Name:SOUTH RENAL CARE, P.S.C
Entity Type:Organization
Organization Name:SOUTH RENAL CARE, P.S.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:ORTIZ HEREDIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-362-0722
Mailing Address - Street 1:PO BOX 335251
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00733-5251
Mailing Address - Country:US
Mailing Address - Phone:787-840-1455
Mailing Address - Fax:787-848-4657
Practice Address - Street 1:2275 PONCE BY PASS
Practice Address - Street 2:CARIBBEAN MEDICAL CENTRE SUITE 202
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1380
Practice Address - Country:US
Practice Address - Phone:787-840-1445
Practice Address - Fax:787-848-4657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR016621207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR016621OtherPR MEDICAL LICENSE
PR016621OtherPR MEDICAL LICENSE