=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295732535
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRUPO GERIATRICO DE MEDICINA DE FAMILIA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | IJ-3 CALLE PALMA REAL P2 URB ROYAL PALM
-----------------------------------------------------
City | BAYAMON
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00959
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-787-9694
-----------------------------------------------------
Fax | 787-787-9701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | IJ-3 CALLE PALMA REAL P2 URB ROYAL PALM
-----------------------------------------------------
City | BAYAMON
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00959
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-787-9694
-----------------------------------------------------
Fax | 787-787-9701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. CARLOS M. GUTIERREZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-787-9694
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 8723
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 9865
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 7119
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------