Healthcare Provider Details

I. General information

NPI: 1295732535
Provider Name (Legal Business Name): GRUPO GERIATRICO DE MEDICINA DE FAMILIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

IJ-3 CALLE PALMA REAL P2 URB ROYAL PALM
BAYAMON PR
00959
US

IV. Provider business mailing address

IJ-3 CALLE PALMA REAL P2 URB ROYAL PALM
BAYAMON PR
00959
US

V. Phone/Fax

Practice location:
  • Phone: 787-787-9694
  • Fax: 787-787-9701
Mailing address:
  • Phone: 787-787-9694
  • Fax: 787-787-9701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number8723
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number9865
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number7119
License Number StatePR

VIII. Authorized Official

Name: MR. CARLOS M. GUTIERREZ
Title or Position: PRESIDENT
Credential:
Phone: 787-787-9694