MEDICARE: PONCE MEDICAL SCHOOL FOUNDATION INC.

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	103TC0700X	Clinical Psychologist

General Provider Information

NPI Number	:	1548411531
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PONCE MEDICAL SCHOOL FOUNDATION INC.

Provider Business Mailing Address
First Line	:	PO BOX 7004
Second Line	:
City	:	PONCE
State	:	PR
Zip	:	00732-7004
Country	:	US
Telephone Number	:	787-840-0052
Fax Number	:	787-284-3619

Provider Business Practice Location Address
First Line	:	132 CALLE JOSE I QUINTON
Second Line	:
City	:	COAMO
State	:	PR
Zip	:	00769-3041
Country	:	US
Telephone Number	:	787-803-2110
Fax Number	:	787-803-2106

Authorized Official
Title or Position	:	ADMINISTRADOR
Name	:	MR. HECTOR BURGOS
Credential	:
Telephone Number	:	787-614-2972

Provider Enumeration Date	:	10/08/2008
Last Update Date	:	10/08/2008

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