MEDICARE: PRIME OTOLARYNGOLOGY SERVICES, PSC

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	207Y00000X	Otolaryngology Physician	11652	PR

General Provider Information

NPI Number	:	1821542234
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIME OTOLARYNGOLOGY SERVICES, PSC

Provider Business Mailing Address
First Line	:	PO BOX 1036
Second Line	:
City	:	GUAYNABO
State	:	PR
Zip	:	00970-1036
Country	:	US
Telephone Number	:	787-706-4334
Fax Number	:	787-749-0993

Provider Business Practice Location Address
First Line	:	1510 AVE F.D. ROOSEVELT
Second Line	:	MEZZANINE SUITE B
City	:	GUAYNABO
State	:	PR
Zip	:	00968-2602
Country	:	US
Telephone Number	:	787-706-4334
Fax Number	:	787-749-0993

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LISETTE YVONNE PEREZ
Credential	:	M.D.
Telephone Number	:	787-706-4334

Provider Enumeration Date	:	08/15/2016
Last Update Date	:	08/15/2016

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