Healthcare Provider Details

I. General information

NPI: 1255897252
Provider Name (Legal Business Name): PHM INTRAHOSPITAL PHYSICIAN GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2019
Last Update Date: 02/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 CALLE ALDA URB. CARIBE
SAN JUAN PR
00926
US

IV. Provider business mailing address

1551 CALLE ALDA URB. CARIBE
SAN JUAN PR
00926
US

V. Phone/Fax

Practice location:
  • Phone: 787-625-2500
  • Fax:
Mailing address:
  • Phone: 787-625-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERTO LUIS BENGOA
Title or Position: PRESIDENT
Credential:
Phone: 787-625-2500