Healthcare Provider Details

I. General information

NPI: 1528332038
Provider Name (Legal Business Name): PROSALUD MEDICAL CENTER PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2012
Last Update Date: 06/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROAD 474 KM 2.2
ISABELA PR
00662-0000
US

IV. Provider business mailing address

PO BOX 1927
ISABELA PR
00662-1927
US

V. Phone/Fax

Practice location:
  • Phone: 787-648-9085
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number17985
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberTXR
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License NumberTXR
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. HUBER A. TAVAREZ GONZALEZ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 787-648-9085