MEDICARE: ALD NEPHROLOGY PSC

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	174400000X	Specialist	17173	PR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	17173	OTHER	PR	LICENCIA

General Provider Information

NPI Number	:	1467725754
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALD NEPHROLOGY PSC

Provider Business Mailing Address
First Line	:	ESTANCIAS DEL BLVD
Second Line	:	143
City	:	SAN JUAN
State	:	PR
Zip	:	00926-9570
Country	:	US
Telephone Number	:	787-726-7008
Fax Number	:	787-726-7083

Provider Business Practice Location Address
First Line	:	611 CALLE PAVIA
Second Line	:	OFIC 214
City	:	SAN JUAN
State	:	PR
Zip	:	00909-2239
Country	:	US
Telephone Number	:	787-726-7008
Fax Number	:	787-726-7083

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ANTONIO DIAZ HERNANDEZ
Credential	:	MD
Telephone Number	:	787-726-7008

Provider Enumeration Date	:	02/16/2012
Last Update Date	:	02/16/2012

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