Basic Information
| Provider Information | |||||||||
| NPI: | 1528046075 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIX MEDICAL GROUP, S.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11913 | ||||||||
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| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009221913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7879990753 | ||||||||
| FaxNumber: | 7879990789 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 CALLE 1 STE 202 | ||||||||
| Address2: | METRO OFFICE PARK | ||||||||
| City: | GUAYNABO | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009680032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7879990753 | ||||||||
| FaxNumber: | 7879990789 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 07/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | CHINEA | ||||||||
| AuthorizedOfficialFirstName: | SHIRLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT ASSOCIATE | ||||||||
| AuthorizedOfficialTelephone: | 7879990753 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0402X | PR | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 207PP0204X | PR | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine | 2080P0203X | PR | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0207X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology | 2080P0210X | PR | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology | 2080P0008X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neurodevelopmental Disabilities | 2080N0001X | PR | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1528046075 | 01 | PR | TAX ID | OTHER |