Provider Demographics
NPI:1548241482
Name:SOUTHERN CARDIOVASCULAR SURGERY
Entity Type:Organization
Organization Name:SOUTHERN CARDIOVASCULAR SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SALVADOR
Authorized Official - Middle Name:
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-840-4030
Mailing Address - Street 1:PO BOX 330230
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00733-0230
Mailing Address - Country:US
Mailing Address - Phone:787-840-4030
Mailing Address - Fax:787-840-4310
Practice Address - Street 1:5 CALLE GUADALUPE
Practice Address - Street 2:SAN LUCAS I, EDIF FRANCISCO REVS
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00730-3111
Practice Address - Country:US
Practice Address - Phone:787-840-4030
Practice Address - Fax:787-840-4310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8605208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
9500000OtherHUMANA
PR60100OtherCRUZ AZUL
88703OtherSSS
D08529Medicare UPIN
9500000OtherHUMANA