MEDICARE: DR. GRACE RULLAN MD

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	174400000X	Specialist	8720	PR
2	2080A0000X	Pediatric Adolescent Medicine Physician	8720	PR

General Provider Information

NPI Number	:	1093715997
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GRACE RULLAN MD

Provider Business Mailing Address
First Line	:	B13 CALLE 5
Second Line	:	PRADO ALTO
City	:	GUAYNABO
State	:	PR
Zip	:	00966-3042
Country	:	US
Telephone Number	:	787-784-0063
Fax Number	:	787-784-0063

Provider Business Practice Location Address
First Line	:	JR5 CALLE LIZZIE GRAHAM
Second Line	:	LEVITTOWN
City	:	TOA BAJA
State	:	PR
Zip	:	00949-3637
Country	:	US
Telephone Number	:	787-784-0063
Fax Number	:	787-784-0069

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2005
Last Update Date	:	12/04/2015

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