Healthcare Provider Details

I. General information

NPI: 1164774972
Provider Name (Legal Business Name): GEMELLE MEDICAL SERVICES PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2012
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR. #2 KM 30 SECTOR ESPINOSA 17-D
VEGA ALTA PR
00692
US

IV. Provider business mailing address

PO BOX 1774
VEGA ALTA PR
00692-1774
US

V. Phone/Fax

Practice location:
  • Phone: 787-915-6224
  • Fax: 787-915-6223
Mailing address:
  • Phone: 787-915-6224
  • Fax: 787-915-6223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16,100
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number17607
License Number StatePR

VIII. Authorized Official

Name: MARISOL SANTIAGO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 787-915-6224