1407270606 NPI number — INTERNAL MEDICINE CANOVANAS GROUP CORP.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407270606 NPI number — INTERNAL MEDICINE CANOVANAS GROUP CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERNAL MEDICINE CANOVANAS GROUP CORP.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407270606
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 20000
Provider Second Line Business Mailing Address:
PMB 121
Provider Business Mailing Address City Name:
CANOVANAS
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-256-0848
Provider Business Mailing Address Fax Number:
787-256-2990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
48 CALLE ORQUIDEA
Provider Second Line Business Practice Location Address:
URB LOIZA VALLEY
Provider Business Practice Location Address City Name:
CANOVANAS
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00729-3596
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-256-0848
Provider Business Practice Location Address Fax Number:
787-256-2990
Provider Enumeration Date:
02/07/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MERINO
Authorized Official First Name:
LOURDES
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
787-256-0848

Provider Taxonomy Codes

  • Taxonomy code: 2083P0901X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: HQ871A . This is a "MEDICARE PTAN" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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