Basic Information
| Provider Information | |||||||||
| NPI: | 1205052248 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRO MEDICO DEL TURABO INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRUPO OB GYN FAJARDO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4980 | ||||||||
| Address2: | |||||||||
| City: | CAGUAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007264980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7876533434 | ||||||||
| FaxNumber: | 7876533517 | ||||||||
| 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: | 04/18/2007 | ||||||||
| LastUpdateDate: | 08/12/2013 | ||||||||
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| 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 | 207V00000X | 8463 | PR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | MEDICAL LICENSE | 01 | PR | 5654 | OTHER | MEDICAL LICENSE | 01 | PR | 13165 | OTHER | MEDICAL LICENSE | 01 | PR | 8463 | OTHER | MEDICAL LICENSE | 01 | PR | 15942 | OTHER | MEDICAL LICENSE | 01 | PR | 9891 | OTHER | MEDICAL LICENSE | 01 | PR | 5326 | OTHER | MEDICAL LICENSE | 01 | PR | 13961 | OTHER | MEDICAL LICENSE | 01 | PR | 4675 | OTHER | MEDICAL LICENSE | 01 | PR | 14791 | OTHER |