Provider Demographics
NPI:1891104188
Name:SOUTHWEST OTO AND HEAD & NECK SURGERY,PSC
Entity Type:Organization
Organization Name:SOUTHWEST OTO AND HEAD & NECK SURGERY,PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMENECH FAGUNDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-290-3333
Mailing Address - Street 1:PO BOX 2000
Mailing Address - Street 2:PMB 137
Mailing Address - City:MERCEDITA
Mailing Address - State:PR
Mailing Address - Zip Code:00715
Mailing Address - Country:US
Mailing Address - Phone:787-290-3333
Mailing Address - Fax:787-290-4444
Practice Address - Street 1:TORRE MED SAN LUCAS
Practice Address - Street 2:AVE. TITO CASTRO
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-4728
Practice Address - Country:US
Practice Address - Phone:787-290-3333
Practice Address - Fax:787-290-4444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13247207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG76827Medicare UPIN
PR0020400Medicare PIN