Provider Demographics
NPI:1629099494
Name:SANTIAGO, EDISSON SR (TEM)
Entity Type:Individual
Prefix:MR
First Name:EDISSON
Middle Name:
Last Name:SANTIAGO
Suffix:SR
Gender:M
Credentials:TEM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 141316
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00614-1316
Mailing Address - Country:US
Mailing Address - Phone:787-898-0698
Mailing Address - Fax:787-820-3198
Practice Address - Street 1:CAMUY ARRIBA
Practice Address - Street 2:STREET 119 KM 11.1 INT
Practice Address - City:CAMUY
Practice Address - State:PR
Practice Address - Zip Code:00627-0000
Practice Address - Country:US
Practice Address - Phone:787-898-0698
Practice Address - Fax:787-820-3198
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRTCAMB407341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR57984OtherTRIPLE S
PR0057984Medicare PIN