Basic Information
| Provider Information | |||||||||
| NPI: | 1063541019 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GENETIC DIAGNOSTIC GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 87 | ||||||||
| Address2: | |||||||||
| City: | MAYAGUEZ | ||||||||
| State: | PR | ||||||||
| PostalCode: | 006810087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877288316 | ||||||||
| FaxNumber: | 7877288316 | ||||||||
| Practice Location | |||||||||
| Address1: | 252 SAN JORGE STREET | ||||||||
| Address2: | SAN JORGE MEDICAL BUILDING SUITE 408 | ||||||||
| City: | SANTURCE | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009120000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877288316 | ||||||||
| FaxNumber: | 7877288316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SANTIAGO CORNIER | ||||||||
| AuthorizedOfficialFirstName: | ALBERTO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7877288316 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207SG0201X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) |
No ID Information.