Healthcare Provider Details

I. General information

NPI: 1114050879
Provider Name (Legal Business Name): INTERNAL MEDICINE PROFESSIONAL SERVICES, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 AVE DOMENECH STE 408 LAS AMERICAS PROFESSIONAL CENTER
SAN JUAN PR
00918-3706
US

IV. Provider business mailing address

PO BOX 10714
SAN JUAN PR
00922-0714
US

V. Phone/Fax

Practice location:
  • Phone: 787-633-3615
  • Fax:
Mailing address:
  • Phone: 787-633-3615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1800X
TaxonomyCorporate Health Clinic/Center
License Number10015
License Number StatePR

VIII. Authorized Official

Name: DR. ANGEL R. SEPULVEDA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 787-633-3615