Basic Information
| Provider Information | |||||||||
| NPI: | 1477537892 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRUPO INTENSIVO PEDIATRICO DE SAN JUAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 252 CALLE SAN JORGE | ||||||||
| Address2: | MEDICAL OFFICE BUILDING SUITE 406 | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009123310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877260210 | ||||||||
| FaxNumber: | 7877285136 | ||||||||
| Practice Location | |||||||||
| Address1: | 252 CALLE SAN JORGE | ||||||||
| Address2: | MEDICAL OFFICE BUILDING SUITE 406 | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009123310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877260210 | ||||||||
| FaxNumber: | 7877285136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RODRIGUEZ-SANTANA | ||||||||
| AuthorizedOfficialFirstName: | JOSE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7877260210 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | PR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 89351 | 01 | PR | TRIPLE S | OTHER |