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General NPI Number Information
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NPI Number | 1457670291
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Entity Type | Organization
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Legal Business Name | INTERNATIONAL CLINITIAN MEDICAL GROUP PS
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Dates
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Enumeration Date | 05/19/2010
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Last Update Date | 05/19/2010
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Provider Practice Location Address
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Address Line | AVE HOSTO #54
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City | SAN JUAN
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State | PR
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Zip | 00919
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Country | US
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Telephone | 787-587-5410
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1198
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City | BAYAMON
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State | PR
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Zip | 00960-1198
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | PEDRO CARRAZANA
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Credential |
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Telephone | 787-587-5410
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 15309
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License Number State | PR
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