Provider Demographics
NPI:1265711667
Name:UROLOGICAL PROFESSIONAL SERVICES PSC
Entity type:Organization
Organization Name:UROLOGICAL PROFESSIONAL SERVICES PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BAEZ TELLADO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-432-7073
Mailing Address - Street 1:BOX 801453
Mailing Address - Street 2:
Mailing Address - City:COTO LAUREL
Mailing Address - State:PR
Mailing Address - Zip Code:00780-1453
Mailing Address - Country:US
Mailing Address - Phone:787-432-7073
Mailing Address - Fax:787-848-0318
Practice Address - Street 1:2225 PONCE BY PASS
Practice Address - Street 2:SUITE 504
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1321
Practice Address - Country:US
Practice Address - Phone:787-432-7073
Practice Address - Fax:787-848-0318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12897208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0090179Medicare Oscar/Certification