=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689810699
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMARY PHYSICIAN CARE PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2008
-----------------------------------------------------
Last Update Date | 06/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 361 CALLE SGTO LUIS MEDINA EXT ROOSEVELT
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00918-3817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-763-6432
-----------------------------------------------------
Fax | 855-304-1818
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 138 AVE WINSTON CHURCHILL PMB 659
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00926-6013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-614-5231
-----------------------------------------------------
Fax | 855-304-1818
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. ALEIDA G NIEVES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-614-5231
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2083P0011X
-----------------------------------------------------
Taxonomy Name | Undersea and Hyperbaric Medicine (Preventive Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------