MEDICARE: BROKEN BONE ORTHO CSP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	4470	PR

General Provider Information

NPI Number	:	1215266564
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROKEN BONE ORTHO CSP

Provider Business Mailing Address
First Line	:	PO BOX 366905
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00936-6905
Country	:	US
Telephone Number	:	787-756-6999
Fax Number	:	787-765-7880

Provider Business Practice Location Address
First Line	:	369 CALLE DE DIEGO STE 202
Second Line	:	TORRE SAN FRANCISCO
City	:	SAN JUAN
State	:	PR
Zip	:	00923-3004
Country	:	US
Telephone Number	:	787-756-6999
Fax Number	:	787-765-7880

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. RAFAEL OTERO
Credential	:	MD
Telephone Number	:	787-756-6999

Provider Enumeration Date	:	12/16/2009
Last Update Date	:	08/10/2011

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