Provider Demographics
NPI:1851376040
Name:PRESBYTERIAN MEDICAL ANESTHESIA GROUP
Entity Type:Organization
Organization Name:PRESBYTERIAN MEDICAL ANESTHESIA GROUP
Other - Org Name:PRESBYTERIAN RESPIRATORY CARE SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATIVE PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BELISARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTA DE JUAN
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:787-725-7860
Mailing Address - Street 1:1451 ASHFORD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00907-1511
Mailing Address - Country:US
Mailing Address - Phone:787-725-7860
Mailing Address - Fax:787-722-3630
Practice Address - Street 1:PMB 423 1357 ASHFORD AVENUE
Practice Address - Street 2:SUITE 2
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907-1420
Practice Address - Country:US
Practice Address - Phone:787-725-7860
Practice Address - Fax:787-722-3630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4154207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0024155Medicare ID - Type UnspecifiedANESTHESIA MEDICAL GROUP