# MD RENAL GROUP LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** MD Renal Group LLC
- **Organization subpart:** No

## Provider details

- **NPI number:** 1043595291
- **Authorized official:** PROF. MAYRA I SANTIAGO M.A. (ADMINISTRATIVE CHIEF OFFICER)
- **Authorized official phone:** (939) 639-0557

## Contact information

- **Practice address:** AVENUE SEVERIANO CUEVAS 18, HOSPITAL BUEN SAMARITANO GROUND FLOOR, AGUADILLA, PR 00605-9026
- **Practice address phone:** (787) 997-0101
- **Mailing address:** PO BOX 667, MOCA, PR 00676-0667
- **Mailing address phone:** (787) 997-0101

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 302F00000X | Exclusive Provider Organization | 17129 | PR | Yes |

## Other

- **Enumeration date:** 10/19/2011
- **Last updated:** 08/14/2012

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 1043595291 | NPI | PR |