Provider Demographics
NPI:1982906400
Name:PUERTO MEDICAL GROUP PSC
Entity Type:Organization
Organization Name:PUERTO MEDICAL GROUP PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALFONSO
Authorized Official - Middle Name:
Authorized Official - Last Name:PUERTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-899-1246
Mailing Address - Street 1:PO BOX 436809
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40253-6809
Mailing Address - Country:US
Mailing Address - Phone:502-899-1246
Mailing Address - Fax:234-567-4229
Practice Address - Street 1:10806 WARD AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-2659
Practice Address - Country:US
Practice Address - Phone:502-899-1246
Practice Address - Fax:234-567-4229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-04
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYLL339208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1669415808OtherINDIVIDUAL NPI