1902236599 NPI number — MRS. MARIAN GONZALEZ BERMUDEZ

Table of content: MRS. MARIAN GONZALEZ BERMUDEZ (NPI 1902236599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902236599 NPI number — MRS. MARIAN GONZALEZ BERMUDEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALEZ BERMUDEZ
Provider First Name:
MARIAN
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1902236599
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 193069
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN JUAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00919-3069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-761-0036
Provider Business Mailing Address Fax Number:
787-292-5050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CARR 2KM 48.3 CALLE JOSE CONDELAS OFIC. 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANATI
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00674-5507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-884-4629
Provider Business Practice Location Address Fax Number:
787-854-3471
Provider Enumeration Date:
11/18/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 231H00000X , with the licence number:  650 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 118455100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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