Healthcare Provider Details

I. General information

NPI: 1245665140
Provider Name (Legal Business Name): PEDIATRICS & SPORTS MEDICINE P.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2013
Last Update Date: 08/14/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

URB SANTA JUANITA, CALLE QUINTANA BH9
BAYAMON PR
00956
US

IV. Provider business mailing address

PO BOX 12336
SAN JUAN PR
00914-0336
US

V. Phone/Fax

Practice location:
  • Phone: 939-264-1889
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH FERNANDEZ
Title or Position: PRESIDENT
Credential: M.D.
Phone: 732-456-0209