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General NPI Number Information
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NPI Number | 1043412752
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Entity Type | Organization
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Legal Business Name | SAN JORGE CHILDREN'S MEDICAL SPECIALTIES,PSC
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Dates
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Enumeration Date | 06/04/2007
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Last Update Date | 08/07/2024
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Provider Practice Location Address
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Address Line | 252 CALLE SAN JORGE
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City | SAN JUAN
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State | PR
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Zip | 00912-3239
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Country | US
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Telephone | 787-728-1575
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Fax | 787-726-0402
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Provider Business Mailing Address
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Address Line | 252 CALLE SAN JORGE
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City | SAN JUAN
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State | PR
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Zip | 00912-3239
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Country | US
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Telephone | 787-728-1575
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Fax | 787-726-0402
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. LUIS A. CLAVELL
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Credential | M.D.
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Telephone | 787-728-1575
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QX0200X
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Taxonomy Name | Oncology Clinic/Center
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License Number | 05-B-1068
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License Number State | PR
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 5762
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License Number State | PR
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