MEDICARE: MOH PEDS OTO 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	174400000X	Specialist

General Provider Information

NPI Number	:	1922343144
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOH PEDS OTO CSP

Provider Business Mailing Address
First Line	:	PO BOX 362707
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00936-2707
Country	:	US
Telephone Number	:	787-268-2300
Fax Number	:	787-268-3055

Provider Business Practice Location Address
First Line	:	252 CALLE SAN JORGE STE 501
Second Line	:	SAN JORGE MEDICAL BUILDING
City	:	SAN JUAN
State	:	PR
Zip	:	00912-3241
Country	:	US
Telephone Number	:	787-268-2300
Fax Number	:	787-268-3055

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MELISSA ORTIZ HERNANDEZ
Credential	:	MD
Telephone Number	:	787-268-2300

Provider Enumeration Date	:	11/28/2012
Last Update Date	:	11/28/2012

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