=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659771145
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUALITY CARE PHYSICIANS, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2014
-----------------------------------------------------
Last Update Date | 09/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARRETERA 2 KM 31.9 BO. BAJURA
-----------------------------------------------------
City | VEGA ALTA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-270-3330
-----------------------------------------------------
Fax | 787-915-7597
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | CARRETERA # 2 KM 31.9 BO. BAJURA
-----------------------------------------------------
City | VEGA ALTA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-270-3330
-----------------------------------------------------
Fax | 787-915-7597
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACTIVE MEMBER
-----------------------------------------------------
Name | DR. LUIS MANUEL GONZALEZ BERMSDEZ
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 787-316-1212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------