Basic Information
| Provider Information | |||||||||
| NPI: | 1841295557 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAINT LUKES MEMORIAL HOSPITAL INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HOSPITAL SAN LUCAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 336810 | ||||||||
| Address2: | |||||||||
| City: | PONCE | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007336810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878442080 | ||||||||
| FaxNumber: | 7878447506 | ||||||||
| Practice Location | |||||||||
| Address1: | 917 AVE TITO CASTRO | ||||||||
| Address2: | |||||||||
| City: | PONCE | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007164717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878442080 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 08/31/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GUILLEN | ||||||||
| AuthorizedOfficialFirstName: | IAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7878442080 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | 08/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | N | Hospital Units | Psychiatric Unit | 282N00000X | 5 | PR | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 10826 | 01 | PR | TRIPLE S | OTHER | 660191960 | 01 | PR | MAPFRE & OTHERS | OTHER | 19020 | 01 | PR | TRIPLE S | OTHER | 19826 | 01 | PR | TRIPLE S | OTHER | 7310370 | 01 | PR | HUMANA | OTHER | 31225 | 01 | PR | TRIPLE S | OTHER | 31247 | 01 | PR | TRIPLE S | OTHER | 5501466 | 01 | PR | ACAA ASC | OTHER | 92399 | 01 | PR | TRIPLE S | OTHER | 18826 | 01 | PR | TRIPLE S | OTHER | 300115 | 01 | PR | UTI | OTHER | 304264 | 01 | PR | ACAA TERAPIA FISICA | OTHER | 18020 | 01 | PR | TRIPLE S | OTHER | 4855 | 01 | PR | IMC | OTHER | 66011960B | 01 | PR | MCS | OTHER | 700009 | 01 | PR | MMM | OTHER | 31225 | 01 | PR | TRIPLE C | OTHER | 5001587 | 01 | PR | ACAA HOSP/ER | OTHER |