MEDICARE: AYALA ORTA MEDICAL SERVICE PSC

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	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10028W	OTHER	PR	MMM
2	2909	OTHER	PR	PMC

General Provider Information

NPI Number	:	1235229931
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AYALA ORTA MEDICAL SERVICE PSC

Provider Business Mailing Address
First Line	:	PO BOX 6431
Second Line	:
City	:	MAYAGUEZ
State	:	PR
Zip	:	00681-6431
Country	:	US
Telephone Number	:	787-827-2433
Fax Number	:

Provider Business Practice Location Address
First Line	:	81 AVE MATIAS BRUGMAN
Second Line	:
City	:	LAS MARIAS
State	:	PR
Zip	:	00670-2008
Country	:	US
Telephone Number	:	787-827-2433
Fax Number	:

Authorized Official
Title or Position	:	PROPIETARIA
Name	:	DR. BRENDA ORTA CARDONA
Credential	:
Telephone Number	:	787-827-2433

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	08/06/2012

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