MEDICARE: SANTOS SANTIAGO MEDINA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	6223	PR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	7330017	OTHER	HUMANA
2	209302	OTHER	UTI
3	600090	OTHER	MMM
4	6424	OTHER	IMC
5	PE 3807	OTHER	PALIC
6	067249	OTHER	CRUZ AZUL
7	3706223	OTHER	UIA
8	80918	OTHER	TRIPLE S

General Provider Information

NPI Number	:	1255318598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANTOS SANTIAGO MEDINA MD

Provider Business Mailing Address
First Line	:	PO BOX 800378
Second Line	:
City	:	COTO LAUREL
State	:	PR
Zip	:	00780-0378
Country	:	US
Telephone Number	:	787-841-1141
Fax Number	:	787-841-1142

Provider Business Practice Location Address
First Line	:	AVE LAS AMERICAS 2401
Second Line	:	EDIFICIO PORRATA PILA #207
City	:	PONCE
State	:	PR
Zip	:	00717-2115
Country	:	US
Telephone Number	:	787-841-1141
Fax Number	:	787-841-1142

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2005
Last Update Date	:	06/04/2014

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