Basic Information
Provider Information | |||||||||
NPI: | 1992855746 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EL MEDICO VISITANTE...,P.S.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 364422 | ||||||||
Address2: |   | ||||||||
City: | SAN JUAN | ||||||||
State: | PR | ||||||||
PostalCode: | 009364422 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7873854924 | ||||||||
FaxNumber: | 7877715151 | ||||||||
Practice Location | |||||||||
Address1: | 951 AVE AMERICO MIRANDA | ||||||||
Address2: | REPARTO METROPOLITANO | ||||||||
City: | SAN JUAN | ||||||||
State: | PR | ||||||||
PostalCode: | 009212801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7873854924 | ||||||||
FaxNumber: | 7877715151 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/12/2007 | ||||||||
LastUpdateDate: | 12/11/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROSSO | ||||||||
AuthorizedOfficialFirstName: | ROBERTO | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENTE | ||||||||
AuthorizedOfficialTelephone: | 7873854924 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X |   | PR | Y |   | Managed Care Organizations | Health Maintenance Organization |   |
No ID Information.