=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205229200
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVANTSURGICAL PR PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2015
-----------------------------------------------------
Last Update Date | 07/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 WASHINGTON STREET ASHFORD MEDICAL CENTER SUITE 505
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-721-2243
-----------------------------------------------------
Fax | 787-721-2204
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | G-9 AVE SAN PATRICIO APT 101
-----------------------------------------------------
City | GUAYNABO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-242-2085
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. EDUARDO LUIS CHINEA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 787-242-2085
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 17884
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------