Basic Information
| Provider Information | |||||||||
| NPI: | 1689312241 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROMEDICON PR INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 FRONT ST STE 280 | ||||||||
| Address2: | |||||||||
| City: | CONSHOHOCKEN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194282891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4843518459 | ||||||||
| FaxNumber: | 4843518810 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 AVE MUNOZ RIVERA | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009183300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4843518459 | ||||||||
| FaxNumber: | 4843518810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2022 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | DOBBINS | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4843518459 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.