MEDICARE: ISLAND MEDICAL 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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1104254150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ISLAND MEDICAL GROUP

Provider Business Mailing Address
First Line	:	PO BOX 16327
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00908-6327
Country	:	US
Telephone Number	:	787-306-8356
Fax Number	:

Provider Business Practice Location Address
First Line	:	CALLE MARGINAL
Second Line	:	E7
City	:	BAYAMON
State	:	PR
Zip	:	00957-2536
Country	:	US
Telephone Number	:	787-306-8356
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ARCILIO ALVARADO
Credential	:
Telephone Number	:	787-306-8356

Provider Enumeration Date	:	10/29/2013
Last Update Date	:	10/29/2013

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