Basic Information
| Provider Information | |||||||||
| NPI: | 1326648379 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARRILLO CARDIOVASCULAR MEDICINE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | URB. QUINTAS DE SAN LUIS | ||||||||
| Address2: | CALLE CAMPECHE A6 | ||||||||
| City: | CAGUAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7873722044 | ||||||||
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| Practice Location | |||||||||
| Address1: | AVE FONT MARTELLO 856 | ||||||||
| Address2: | HOSPITAL RYDER SUITE 105 | ||||||||
| City: | HUMACAO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 00791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7879204090 | ||||||||
| FaxNumber: | 8777362593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2020 | ||||||||
| LastUpdateDate: | 10/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | CARRILLO NAVAS | ||||||||
| AuthorizedOfficialFirstName: | JUAN | ||||||||
| AuthorizedOfficialMiddleName: | ERNESTO | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7873722044 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.