Healthcare Provider Details

I. General information

NPI: 1063519122
Provider Name (Legal Business Name): PONCE ADVANCE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE FERROCARRIL INT AVE MUNOZ RIVERA CENTRO COMERCIAL SANTA MARIA LOCAL 4
PONCE PUERTO RICO
00717
UM

IV. Provider business mailing address

PMB 282 1575 MUNOZ RIVERA AVE.
PONCE PUERTO RICO
00717
UM

V. Phone/Fax

Practice location:
  • Phone: 787-651-4544
  • Fax: 787-651-4544
Mailing address:
  • Phone: 787-813-2324
  • Fax: 787-841-3908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number07-B-2318
License Number StatePR

VIII. Authorized Official

Name: MR. RICARDO E JIMENEZ RIVERA
Title or Position: DIRECTOR EJECUTIVO
Credential:
Phone: 787-651-4544