Basic Information
| Provider Information | |||||||||
| NPI: | 1083758163 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRO MEDICO DEL TURABO INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GRUPO EMERGENCIAS PEDIATRICAS FAJARDO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4980 | ||||||||
| Address2: | |||||||||
| City: | CAGUAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7876533434 | ||||||||
| FaxNumber: | 7879611901 | ||||||||
| Practice Location | |||||||||
| Address1: | HIMA SAN PABLO FAJARDO | ||||||||
| Address2: | AVE GENERAL VALERO 404 | ||||||||
| City: | FAJARDO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7876550505 | ||||||||
| FaxNumber: | 7876555086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 08/12/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RIVERA | ||||||||
| AuthorizedOfficialFirstName: | ORLANDO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7876533434 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LCDO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PP0204X | 6893 | PR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 11744 | 01 | PR | MEDICAL LICENSE | OTHER | 6893 | 01 | PR | MEDICAL LICENSE | OTHER | 7291 | 01 | PR | MEDICAL LICENSE | OTHER | 14540 | 01 | PR | MEDICAL LICENSE | OTHER | 10792 | 01 | PR | MEDICAL LICENSE | OTHER | 12373 | 01 | PR | MEDICAL LICENSE | OTHER | 12929 | 01 | PR | MEDICAL LICENSE | OTHER | 10483 | 01 | PR | MEDICAL LICENSE | OTHER | 4494 | 01 | PR | MEDICAL LICENSE | OTHER |