Provider Demographics
NPI:1760583504
Name:PONCE SCHOOL OF MEDICINE PRACTICE GROUP
Entity Type:Organization
Organization Name:PONCE SCHOOL OF MEDICINE PRACTICE GROUP
Other - Org Name:PSM PRACTICE GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-614-2972
Mailing Address - Street 1:PO BOX 7004
Mailing Address - Street 2:PONCE SCHOOL OF MEDICINE PRACTICE GROUP
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00732-7004
Mailing Address - Country:US
Mailing Address - Phone:787-840-0052
Mailing Address - Fax:787-840-2317
Practice Address - Street 1:ANN D PEREZ MARSHAND ST LOTE 2
Practice Address - Street 2:URB INDUSTRIAL REPARADA
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00732-7004
Practice Address - Country:US
Practice Address - Phone:787-840-0052
Practice Address - Fax:787-284-3619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4650E261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty