Provider Demographics
NPI:1942294012
Name:INSTITUTO DE GASTROENTEROLOGIA DE P.R.
Entity Type:Organization
Organization Name:INSTITUTO DE GASTROENTEROLOGIA DE P.R.
Other - Org Name:INST GASTROENTEROLOGIA
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PRUDENCIO
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAUREANO
Authorized Official - Suffix:
Authorized Official - Credentials:MHSA
Authorized Official - Phone:787-764-8787
Mailing Address - Street 1:400 AVE F.D, ROOSEVELT AVE.
Mailing Address - Street 2:SUITE 206
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918
Mailing Address - Country:US
Mailing Address - Phone:787-764-8787
Mailing Address - Fax:787-250-1029
Practice Address - Street 1:400 AVE F.D. ROOSEVELT AVE.
Practice Address - Street 2:SUITE 206
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918
Practice Address - Country:US
Practice Address - Phone:787-764-8787
Practice Address - Fax:787-250-1029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-06
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR207RG0100X
207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR24118Medicare PIN