Basic Information
| Provider Information | |||||||||
| NPI: | 1316022312 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RECINTO DE CIENCIAS MEDICAS | ||||||||
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| OtherOrganizationName: | RECINTO DE CIENCIAS MEDICAS (NEUROCIRUGIA ENDOVASCULAR RCM) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 29134 | ||||||||
| Address2: | NEUROCIRUGIA ENDOVASCULAR RCM | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009290134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877540101 | ||||||||
| FaxNumber: | 7872748156 | ||||||||
| Practice Location | |||||||||
| Address1: | CENTRO MEDICO DE PR EDIF PRINCIPAL RCM OFIC 563 | ||||||||
| Address2: | ESCUELA DE MEDICINA PPMI APTDO. 29134 | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009290134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877582525 | ||||||||
| FaxNumber: | 7872748156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 09/30/2011 | ||||||||
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| AuthorizedOfficialLastName: | TROCHE | ||||||||
| AuthorizedOfficialFirstName: | MYRIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7877582525 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RHIA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0204X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 207T00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 12 | 01 | PR | PPMI GROUP | OTHER |