Healthcare Provider Details

I. General information

NPI: 1093298176
Provider Name (Legal Business Name): MTG PEDIATRIC GROUP PSG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2018
Last Update Date: 09/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE HERNANDEZ CARRION URB. ATENAS
MANATI PR
00674
US

IV. Provider business mailing address

P.O. BOX 8901 PMB 022
HATILLO PR
00659
US

V. Phone/Fax

Practice location:
  • Phone: 787-621-3700
  • Fax: 787-621-7889
Mailing address:
  • Phone: 787-884-2558
  • Fax: 787-621-7889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MARILYN TOLDEO
Title or Position: PRESIDENT
Credential: MD
Phone: 787-884-2558