Provider Demographics
NPI:1851658249
Name:PLAZA MAGNOLIA MEDICAL, INC
Entity Type:Organization
Organization Name:PLAZA MAGNOLIA MEDICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:SANTIAGO PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:1787-288-3805
Mailing Address - Street 1:P. O. BOX 596
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00960
Mailing Address - Country:UM
Mailing Address - Phone:1787-288-3805
Mailing Address - Fax:1787-269-9600
Practice Address - Street 1:CALLE 10 O 13
Practice Address - Street 2:MAGNOLIA GARDENS
Practice Address - City:BAYAMON
Practice Address - State:PUERTO RICO
Practice Address - Zip Code:00956
Practice Address - Country:UM
Practice Address - Phone:1787-288-3805
Practice Address - Fax:1787-269-9600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11341261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG41621Medicare UPIN