Healthcare Provider Details

I. General information

NPI: 1821413527
Provider Name (Legal Business Name): SOUTHEAST RENAL GROUP PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2014
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SANTA ISABEL PROFESSIONAL BLDG SUITE 205
SANTA ISABEL PR
00757
US

IV. Provider business mailing address

PO BOX 335432
PONCE PR
00733-5432
US

V. Phone/Fax

Practice location:
  • Phone: 787-971-7133
  • Fax:
Mailing address:
  • Phone: 787-971-7133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. LUIS A ORTIZ HEREDIA
Title or Position: PRESIDENT
Credential:
Phone: 787-971-7133