Provider Demographics
NPI:1821070640
Name:POLICLINICA SAN PEDRO PSC
Entity Type:Organization
Organization Name:POLICLINICA SAN PEDRO PSC
Other - Org Name:CDT POLICLINICA SAN PEDRO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:C
Authorized Official - Last Name:RIVERA IRIZARRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-839-3980
Mailing Address - Street 1:PO BOX 818
Mailing Address - Street 2:
Mailing Address - City:ARROYO
Mailing Address - State:PR
Mailing Address - Zip Code:00714-0818
Mailing Address - Country:US
Mailing Address - Phone:787-839-3980
Mailing Address - Fax:787-271-2515
Practice Address - Street 1:211 CALLE MORSE
Practice Address - Street 2:
Practice Address - City:ARROYO
Practice Address - State:PR
Practice Address - Zip Code:00714-2350
Practice Address - Country:US
Practice Address - Phone:787-839-3980
Practice Address - Fax:787-271-2515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR229261QE0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRHV265AOtherMEDICARE PTAN
PR0084706Medicare ID - Type UnspecifiedMEDICARE CDT
PR373925068OtherPROSSAM
PR=========OtherAMERICAN HEALTH
PR004001478OtherACCA
PR=========OtherCIGNA
PR=========OtherPALIC
PR19154OtherTRIPLE-S
PR7140014OtherHUMANA HEALTH PLAN
PR9964OtherINTERNATIONAL MEDICAL CAR
PR=========OtherMAPHRE
PR=========OtherMEDICAL CARD SYSTEM
PR1400123966OtherGLOBAL
PR=========OtherAETNA
PR=========OtherCOSVI
PR=========OtherPREFERED HEALTH