=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033533179
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MADELINE FERNANDEZ GONZALEZ CSP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2014
-----------------------------------------------------
Last Update Date | 02/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | EDIF A PORRATA PILA 2431 BLVD LUIS A FERRE STE 311
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00717-2116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-843-0003
-----------------------------------------------------
Fax | 787-841-1086
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | EDIF A PORRATA PILA 2431 BLVD LUIS A FERRE STE 311
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00717-2116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-843-0003
-----------------------------------------------------
Fax | 787-841-1086
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MADELINE FERNANDEZ
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 787-843-0003
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 11858
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------