Basic Information
| Provider Information | |||||||||
| NPI: | 1760840821 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TIGER MED MCS-A | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TIGER MED CORP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1357 | ||||||||
| Address2: | |||||||||
| City: | CAGUAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007260000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7872862800 | ||||||||
| FaxNumber: | 7872862805 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 CALLE MUNOZ RIVERA | ||||||||
| Address2: | |||||||||
| City: | CAGUAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007262602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7872862800 | ||||||||
| FaxNumber: | 7872862805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2016 | ||||||||
| LastUpdateDate: | 02/04/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GANDARA | ||||||||
| AuthorizedOfficialFirstName: | ROBERTO | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7875250388 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.