Provider Demographics
NPI:1588988216
Name:SAMBA BRAS MEDICAL, P.S.C
Entity type:Organization
Organization Name:SAMBA BRAS MEDICAL, P.S.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTE
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMIL
Authorized Official - Middle Name:
Authorized Official - Last Name:ABOU EL HOSSEN DUARTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-863-3636
Mailing Address - Street 1:P.O. BOX 823
Mailing Address - Street 2:
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738-0823
Mailing Address - Country:US
Mailing Address - Phone:787-863-3636
Mailing Address - Fax:787-863-3638
Practice Address - Street 1:AVE. GENERAL VALERO 410
Practice Address - Street 2:TORRE MEDICA SAN PABLO OFICINA 409
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738
Practice Address - Country:US
Practice Address - Phone:787-863-3636
Practice Address - Fax:787-863-3638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-24
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11782302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRG41813Medicare UPIN