Healthcare Provider Details

I. General information

NPI: 1023664042
Provider Name (Legal Business Name): SOUTH PRIME OB-GYN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2019
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HOSPITAL DAMAS 2213 PONCE BYPASS
PONCE PR
00717
US

IV. Provider business mailing address

1124 AVE MUNOZ RIVERA
PONCE PR
00717-0643
US

V. Phone/Fax

Practice location:
  • Phone: 787-633-9260
  • Fax:
Mailing address:
  • Phone: 787-633-9260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LENNY G PAGAN
Title or Position: PRESIDENT
Credential: MD
Phone: 787-633-9260