Provider Demographics
NPI:1477841864
Name:EASTERN SURGICAL GROUP PSC
Entity type:Organization
Organization Name:EASTERN SURGICAL GROUP PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:DE JESUS RAMOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-655-4006
Mailing Address - Street 1:AVE GENERAL VALERO # 410
Mailing Address - Street 2:TORRE MEDICA 403
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738-3949
Mailing Address - Country:US
Mailing Address - Phone:787-655-4006
Mailing Address - Fax:787-801-0721
Practice Address - Street 1:AVE GENERAL VALERO # 410
Practice Address - Street 2:TORRE MEDICA 403
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738-3949
Practice Address - Country:US
Practice Address - Phone:787-655-4006
Practice Address - Fax:787-801-0721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-19
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR18210174400000X
PR12253174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0088599Medicare UPIN