Healthcare Provider Details

I. General information

NPI: 1801902705
Provider Name (Legal Business Name): PREMIER SPINE PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 05/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 AVE. DEGETAU HIMA PLAZA I, SUITE 703
CAGUAS PR
00725
US

IV. Provider business mailing address

PO BOX 8637
CAGUAS PR
00726-8637
US

V. Phone/Fax

Practice location:
  • Phone: 787-744-8315
  • Fax: 787-746-4311
Mailing address:
  • Phone: 787-744-8315
  • Fax: 787-746-4311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number12070
License Number StatePR

VIII. Authorized Official

Name: DR. ENRIQUE ESCOBAR-MEDINA
Title or Position: MD
Credential:
Phone: 787-744-8315