MEDICARE: GENETIC DIAGNOSTIC GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207SG0201X	Clinical Genetics (M.D.) Physician

General Provider Information

NPI Number	:	1063541019
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GENETIC DIAGNOSTIC GROUP

Provider Business Mailing Address
First Line	:	PO BOX 87
Second Line	:
City	:	MAYAGUEZ
State	:	PR
Zip	:	00681-0087
Country	:	US
Telephone Number	:	787-728-8316
Fax Number	:	787-728-8316

Provider Business Practice Location Address
First Line	:	252 SAN JORGE STREET
Second Line	:	SAN JORGE MEDICAL BUILDING SUITE 408
City	:	SANTURCE
State	:	PR
Zip	:	00912-0000
Country	:	US
Telephone Number	:	787-728-8316
Fax Number	:	787-728-8316

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ALBERTO SANTIAGO CORNIER
Credential	:	M.D.
Telephone Number	:	787-728-8316

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	08/22/2020

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