Basic Information
| Provider Information | |||||||||
| NPI: | 1760698096 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADM SERVICIOS MEDICOS DE PUERTO RICO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CENTRO MEDICO | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2129 | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009222129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877773483 | ||||||||
| FaxNumber: | 7877773481 | ||||||||
| Practice Location | |||||||||
| Address1: | AVE AMERICO MIRANDA | ||||||||
| Address2: | NO 22 BO MONACILLOS | ||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009222129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877773483 | ||||||||
| FaxNumber: | 7877773481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARTAGENA | ||||||||
| AuthorizedOfficialFirstName: | JOSE | ||||||||
| AuthorizedOfficialMiddleName: | RIVERA | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLER OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7877773483 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | SR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | PR | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QH0100X | N | Ambulatory Health Care Facilities | Clinic/Center | Health Service | 261QS0112X | Y | Ambulatory Health Care Facilities | Clinic/Center | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1000042 | 01 | PR | HUMANA | OTHER | 067019 | 01 | PR | CRUZ AZUL | OTHER | 28345 | 01 | PR | SSS | OTHER |