Provider Demographics
NPI:1396041653
Name:TOTALMED SUBIC CORPORATION
Entity Type:Organization
Organization Name:TOTALMED SUBIC CORPORATION
Other - Org Name:AMBULATORY SURGICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:C
Authorized Official - Last Name:RICARDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:047-252-2623
Mailing Address - Street 1:TOTALMED SUBIC CORP GATEWAY PARK #2 BRAVEHEART STREET
Mailing Address - Street 2:SUBIC BAY FREEPORT
Mailing Address - City:OLONGAPO CITY
Mailing Address - State:ZAMBALES
Mailing Address - Zip Code:2222
Mailing Address - Country:PH
Mailing Address - Phone:047-252-2623
Mailing Address - Fax:047-252-8747
Practice Address - Street 1:TOTALMED SUBIC CORP GATEWAY PARK #2 BRAVEHEART STREET
Practice Address - Street 2:SUBIC BAY FREEPORT
Practice Address - City:OLONGAPO CITY
Practice Address - State:ZAMBALES
Practice Address - Zip Code:2222
Practice Address - Country:PH
Practice Address - Phone:047-252-2623
Practice Address - Fax:047-252-8747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-04
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X261QA1903X
261Q00000X2011261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PHL043821PHLOtherTRICARE OVERSEAS