MEDICARE: MARISOL COLLAZO ORTIZ INC

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	291U00000X	Clinical Medical Laboratory	807	PR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	20213	OTHER		PREFERRED MEDICARE CHOICE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	15843	OTHER	AMPR
3	6390009	OTHER	HUMANA HEALTH PLAN
4	6390009	OTHER	HUMANA INSURANCE
5	51539	OTHER	LACRUZ AZUL DE PUERTO RIC
6	LB00746	OTHER	UIA
7	20463	OTHER	AMERICAN HEALTH
8	6390009	OTHER	HUMANA REFORMA
9	30778	OTHER	TRIPLE S
10	0877	OTHER	INTERNATIONAL MEDICAL CAR
11	400123	OTHER	PREFERRED HEALTH UTI

General Provider Information

NPI Number	:	1669518445
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARISOL COLLAZO ORTIZ INC

Provider Business Mailing Address
First Line	:	12 CALLE BARCELO
Second Line	:
City	:	CIDRA
State	:	PR
Zip	:	00739-3446
Country	:	US
Telephone Number	:	787-739-5525
Fax Number	:	787-739-2054

Provider Business Practice Location Address
First Line	:	12 CALLE BARCELO
Second Line	:
City	:	CIDRA
State	:	PR
Zip	:	00739-3446
Country	:	US
Telephone Number	:	787-739-5525
Fax Number	:	787-739-2054

Authorized Official
Title or Position	:	LAB DIRECTOR
Name	:	MRS. MARISOL COLLAZO
Credential	:	MD MT
Telephone Number	:	787-739-5525

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	12/21/2012

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