=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417342262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIGHTWORK ANESTHESIOLOGY SERVICES PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2015
-----------------------------------------------------
Last Update Date | 03/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | ADMINISTRACION SERVICIOS MEDICOS DE PR CENTRO MEDICO DE PR BO MONACILLOS
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-777-3535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 270074
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00928-2874
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-379-5456
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOSE R. ORTIZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 787-379-5456
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367H00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiologist Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------