=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356640486
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINIMALLY INVASIVE UROLOGY CENTER, PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2011
-----------------------------------------------------
Last Update Date | 01/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | ADLER MEDICAL PLAZA, SUITE 304 576 CESAR GONZALEZ AVENUE
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-250-8985
-----------------------------------------------------
Fax | 787-764-6439
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | #576 CESAR GONZALEZ STREET ADLER MEDICAL PLAZA, SUITE 304
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-250-8985
-----------------------------------------------------
Fax | 787-764-6439
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ARTURO COLON-HERDMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 787-250-8985
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 15396
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------