=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942294012
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INSTITUTO DE GASTROENTEROLOGIA DE P.R.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2005
-----------------------------------------------------
Last Update Date | 10/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 AVE F.D. ROOSEVELT AVE. SUITE 206
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-764-8787
-----------------------------------------------------
Fax | 787-250-1029
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 AVE F.D, ROOSEVELT AVE. SUITE 206
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-764-8787
-----------------------------------------------------
Fax | 787-250-1029
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. PRUDENCIO A. LAUREANO
-----------------------------------------------------
Credential | M.H.S.A.
-----------------------------------------------------
Telephone | 787-764-8787
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------