MEDICARE: MR. EDISSON SANTIAGO SR. TEM

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	341600000X	Ambulance	TCAMB407	PR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	57984	OTHER	PR	TRIPLE S

General Provider Information

NPI Number	:	1629099494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EDISSON SANTIAGO SR. TEM

Provider Business Mailing Address
First Line	:	PO BOX 141316
Second Line	:
City	:	ARECIBO
State	:	PR
Zip	:	00614-1316
Country	:	US
Telephone Number	:	787-898-0698
Fax Number	:	787-820-3198

Provider Business Practice Location Address
First Line	:	CAMUY ARRIBA
Second Line	:	STREET 119 KM 11.1 INT
City	:	CAMUY
State	:	PR
Zip	:	00627-0000
Country	:	US
Telephone Number	:	787-898-0698
Fax Number	:	787-820-3198

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	12/04/2007

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