Basic Information
| Provider Information | |||||||||
| NPI: | 1053945022 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DR SUSONI HEALTH COMMUNITY SERVICES CORP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HOSPITAL PAVIA ARECIBO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 659 | ||||||||
| Address2: | |||||||||
| City: | ARECIBO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 006130659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7876507272 | ||||||||
| FaxNumber: | 7876507310 | ||||||||
| Practice Location | |||||||||
| Address1: | CARR, 129 KM 1.0 | ||||||||
| Address2: | AVE SAN LUIS | ||||||||
| City: | ARECIBO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 006130659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7876507272 | ||||||||
| FaxNumber: | 7876507310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2020 | ||||||||
| LastUpdateDate: | 07/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ORTIZ | ||||||||
| AuthorizedOfficialFirstName: | HECTOR | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | FINANCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7876507272 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DR SUSONI HEALTH COMMUNITY SERVICES CORP | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 400087 | 05 | PR | MEDICAID |