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General NPI Number Information
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NPI Number | 1104049121
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Entity Type | Organization
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Legal Business Name | PONCE ADVANCE MEDICAL GROUP
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Dates
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Enumeration Date | 04/10/2007
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Last Update Date | 08/29/2025
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Provider Practice Location Address
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Address Line | CALLE FERROCARRIL INT AVE MUNOZ RIVERA CENTRO COMERCIAL SANTA MARIA LOCAL 4
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City | PONCE
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State | PR
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Zip | 00717-4105
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Country | US
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Telephone | 787-651-4544
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Fax |
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Provider Business Mailing Address
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Address Line | 1575 AVE MUNOZ RIVERA PMB 282,
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City | PONCE
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State | PR
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Zip | 00717-0211
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Country | US
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Telephone | 787-813-2324
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Fax | 787-841-3908
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Authorized Official
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Title or Position | DIRECTOR EJECUTIVO
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Name | RICARDO E JIMENEZ RIVERA
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Credential |
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Telephone | 787-651-4544
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 07-B-2318
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License Number State | PR
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