Basic Information
| Provider Information | |||||||||
| NPI: | 1255319703 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIX MEDICAL GROUP OF PUERTO RICO, P.S.C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11913 | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009221913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7879990753 | ||||||||
| FaxNumber: | 7875351509 | ||||||||
| Practice Location | |||||||||
| Address1: | 1451 AVE ASHFORD | ||||||||
| Address2: | CONDADO | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009071511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877226004 | ||||||||
| FaxNumber: | 7877226003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 07/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | VELAZQUEZ | ||||||||
| AuthorizedOfficialFirstName: | SANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 7879990753 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | PR | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
No ID Information.