Provider Demographics
NPI:1902265887
Name:PUERTO RICO PEDIATRIC SURGERY GROUP PSC
Entity Type:Organization
Organization Name:PUERTO RICO PEDIATRIC SURGERY GROUP PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:J
Authorized Official - Last Name:ZEQUEIRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-403-9370
Mailing Address - Street 1:76 CALLE AQUAMARINA
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-7067
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:76 CALLE AQUAMARINA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-7067
Practice Address - Country:US
Practice Address - Phone:787-403-9370
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-19
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17,8852086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Single Specialty