Healthcare Provider Details

I. General information

NPI: 1366670275
Provider Name (Legal Business Name): ANDREA'S MEDICAL GROUP P.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 GALENO PLAZA SUITE 4 SAN CLALUDIO AVE.
SAN JUAN PR
00926-0000
US

IV. Provider business mailing address

406 CALLE SAN CLAUDIO SUITE 4, SAGRADO CORAZON
SAN JUAN PR
00926-4117
US

V. Phone/Fax

Practice location:
  • Phone: 787-226-5135
  • Fax:
Mailing address:
  • Phone: 787-226-5135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number15891
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number14286
License Number StatePR

VIII. Authorized Official

Name: MR. LUIS ALFONSO BONFIL
Title or Position: ADMINISTRATOR
Credential:
Phone: 787-226-5135