Provider Demographics
NPI:1821413527
Name:SOUTHEAST RENAL GROUP PSC
Entity Type:Organization
Organization Name:SOUTHEAST RENAL GROUP PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:ORTIZ HEREDIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-971-7133
Mailing Address - Street 1:PO BOX 335432
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00733-5432
Mailing Address - Country:US
Mailing Address - Phone:787-971-7133
Mailing Address - Fax:
Practice Address - Street 1:SANTA ISABEL PROFESSIONAL BLDG
Practice Address - Street 2:SUITE 205
Practice Address - City:SANTA ISABEL
Practice Address - State:PR
Practice Address - Zip Code:00757
Practice Address - Country:US
Practice Address - Phone:787-971-7133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-04
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty