Provider Demographics
NPI:1669486643
Name:PONCE MEDICAL SCHOOL FOUNDATION
Entity Type:Organization
Organization Name:PONCE MEDICAL SCHOOL FOUNDATION
Other - Org Name:CENTRO DE SALUD CONDUCTUAL AGUADILLA
Other - Org Type:Other Name
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGOS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:787-840-2575
Mailing Address - Street 1:PO BOX 7004
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00732-7004
Mailing Address - Country:US
Mailing Address - Phone:787-840-2575
Mailing Address - Fax:
Practice Address - Street 1:15 AVE SEVERIANO CUEVAS
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603-5743
Practice Address - Country:US
Practice Address - Phone:787-891-2540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR8-4698Medicare ID - Type UnspecifiedMULTI-SPECIALTY