Basic Information
| Provider Information | |||||||||
| NPI: | 1639696289 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOSPITAL MENONITA GUAYAMA INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HOSPITAL MENONITA DE GUAYAMA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1650 | ||||||||
| Address2: | |||||||||
| City: | CIDRA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007391650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874341700 | ||||||||
| FaxNumber: | 7874341714 | ||||||||
| Practice Location | |||||||||
| Address1: | URB. LA HACIENDA ALBIZU CAMPOS | ||||||||
| Address2: | ESQUINA PRINCIPAL | ||||||||
| City: | GUAYAMA | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007840011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874341700 | ||||||||
| FaxNumber: | 7874341714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2017 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VAZQUEZ RIVERA | ||||||||
| AuthorizedOfficialFirstName: | LISSETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING AND CODING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7874341700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 17-086 | PR | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 400048 | 05 | PR | MEDICAID |