MEDICARE: GRUPO MEDICO CDT DR. MANUEL QUEVEDO BAEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	LIC 2	PR

General Provider Information

NPI Number	:	1326398314
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRUPO MEDICO CDT DR. MANUEL QUEVEDO BAEZ

Provider Business Mailing Address
First Line	:	PO BOX 21405
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00928-1405
Country	:	US
Telephone Number	:	787-480-3876
Fax Number	:	787-977-8401

Provider Business Practice Location Address
First Line	:	SAN AGUSTIN # 359
Second Line	:	PUERTA DE TIERRA
City	:	SAN JUAN
State	:	PR
Zip	:	00901-2938
Country	:	US
Telephone Number	:	787-480-3876
Fax Number	:	787-977-8401

Authorized Official
Title or Position	:	SUB DIRECTOR
Name	:	MISS MARITZA VEGA DE JESUS
Credential	:
Telephone Number	:	787-444-9295

Provider Enumeration Date	:	09/17/2012
Last Update Date	:	09/17/2012

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