Healthcare Provider Details

I. General information

NPI: 1376150680
Provider Name (Legal Business Name): PEDIATRIC & GENERAL SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2020
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 AVE HOSTOS STE 123
MAYAGUEZ PR
00682-1560
US

IV. Provider business mailing address

PO BOX 1605
RINCON PR
00677-1605
US

V. Phone/Fax

Practice location:
  • Phone: 787-314-2325
  • Fax:
Mailing address:
  • Phone: 787-314-2325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JEAN C CARRASQUILLO QUINONES
Title or Position: PRESIDENT
Credential: MD
Phone: 787-314-2325