Basic Information
| Provider Information | |||||||||
| NPI: | 1295020790 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH RENAL CARE, P.S.C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 335251 | ||||||||
| Address2: | |||||||||
| City: | PONCE | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007335251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878401455 | ||||||||
| FaxNumber: | 7878484657 | ||||||||
| Practice Location | |||||||||
| Address1: | 2275 PONCE BY PASS | ||||||||
| Address2: | CARIBBEAN MEDICAL CENTRE SUITE 202 | ||||||||
| City: | PONCE | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007171380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878401445 | ||||||||
| FaxNumber: | 7878484657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2011 | ||||||||
| LastUpdateDate: | 06/13/2011 | ||||||||
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| AuthorizedOfficialLastName: | ORTIZ HEREDIA | ||||||||
| AuthorizedOfficialFirstName: | LUIS | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7873620722 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 016621 | PR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 016621 | 01 | PR | PR MEDICAL LICENSE | OTHER |