Basic Information
| Provider Information | |||||||||
| NPI: | 1164566220 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRO MEDICO DEL TURABO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GRUPO HOSPITALISTAS PEDIATRICOS FAJARDO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| 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: | 05/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| 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 | 208M00000X | 10483 | PR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | $$$$$$$$$ | 01 | PR | SOCIAL SECURITY | OTHER | $$$$$$$$$ | 01 | PR | SOCIAL SECURITY | OTHER |