Basic Information
Provider Information | |||||||||
NPI: | 1528558129 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MENNONITE GENERAL HOSPITAL INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CENTRO RADIOLOGICO HOSPITAL MENONITA, OROCOVIS | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1650 | ||||||||
Address2: |   | ||||||||
City: | CIDRA | ||||||||
State: | PR | ||||||||
PostalCode: | 007391650 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7874341700 | ||||||||
FaxNumber: | 7874341714 | ||||||||
Practice Location | |||||||||
Address1: | 18 AVENIDA LUIS MUNOZ MARIN | ||||||||
Address2: | EDIFICIO ORO OFFICE | ||||||||
City: | OROCOVIS | ||||||||
State: | PR | ||||||||
PostalCode: | 007200000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7874341700 | ||||||||
FaxNumber: | 7874341714 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2018 | ||||||||
LastUpdateDate: | 05/18/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VASQUEZ RIVERA | ||||||||
AuthorizedOfficialFirstName: | LISSETTE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7876530550 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MENNONITE GENERAL HOSPITAL,INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0206X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography |
No ID Information.