Provider Demographics
NPI:1285979633
Name:CLINICA DE MEDICINA PRIMARIA DEL SUR.CSP
Entity type:Organization
Organization Name:CLINICA DE MEDICINA PRIMARIA DEL SUR.CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENT AGENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SONIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-284-6934
Mailing Address - Street 1:442,CALLE HNOS SCHMIDT
Mailing Address - Street 2:EST DEL GOLF CLUB
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CARR 132, KM 24.3 NO. 8
Practice Address - Street 2:CANAS
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00728
Practice Address - Country:US
Practice Address - Phone:787-284-6934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11906302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0089959Medicare PIN