Healthcare Provider Details

I. General information

NPI: 1043595291
Provider Name (Legal Business Name): MD RENAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 08/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVENUE SEVERIANO CUEVAS 18 HOSPITAL BUEN SAMARITANO GROUND FLOOR
AGUADILLA PR
00605-9026
US

IV. Provider business mailing address

PO BOX 667
MOCA PR
00676-0667
US

V. Phone/Fax

Practice location:
  • Phone: 787-997-0101
  • Fax:
Mailing address:
  • Phone: 787-997-0101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number17129
License Number StatePR

VIII. Authorized Official

Name: PROF. MAYRA I SANTIAGO
Title or Position: ADMINISTRATIVE CHIEF OFFICER
Credential: M.A.
Phone: 939-639-0557