Healthcare Provider Details

I. General information

NPI: 1255319703
Provider Name (Legal Business Name): PEDIATRIX MEDICAL GROUP OF PUERTO RICO, P.S.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 AVE ASHFORD CONDADO
SAN JUAN PR
00907-1511
US

IV. Provider business mailing address

PO BOX 11913
SAN JUAN PR
00922-1913
US

V. Phone/Fax

Practice location:
  • Phone: 787-722-6004
  • Fax: 787-722-6003
Mailing address:
  • Phone: 787-999-0753
  • Fax: 787-535-1509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number StatePR

VIII. Authorized Official

Name: SANDY VELAZQUEZ
Title or Position: PROVIDER ENROLLMENT
Credential:
Phone: 787-999-0753