=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770740557
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATENCION MEDICA INMEDIATA CSP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2008
-----------------------------------------------------
Last Update Date | 05/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | AVENIDA RAFAEL CORDERO RAFAEL CORDERO #28
-----------------------------------------------------
City | CAGUAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-258-7020
-----------------------------------------------------
Fax | 787-258-7021
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 193477
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00919-3477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-286-6060
-----------------------------------------------------
Fax | 787-286-6161
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DR. JOSE A RIVERA ORTIZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 787-286-6060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0200X
-----------------------------------------------------
Taxonomy Name | Radiology Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 1056
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QE0002X
-----------------------------------------------------
Taxonomy Name | Emergency Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------