MEDICARE: PUERTO RICO 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	174400000X	Specialist	11058	PR

General Provider Information

NPI Number	:	1548497357
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PUERTO RICO MEDICAL GROUP

Provider Business Mailing Address
First Line	:	1607 AVE PONCE DE LEON
Second Line	:	COBIAN'S PLAZA SUITE GM 4
City	:	SAN JUAN
State	:	PR
Zip	:	00909-1820
Country	:	US
Telephone Number	:	787-923-0062
Fax Number	:

Provider Business Practice Location Address
First Line	:	1607 AVE PONCE DE LEON
Second Line	:	COBIAN'S PLAZA SUITE GM 4
City	:	SAN JUAN
State	:	PR
Zip	:	00909-1820
Country	:	US
Telephone Number	:	787-923-0062
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ANA IVETTE ALVARADO-SANTOS
Credential	:	M.D
Telephone Number	:	787-923-0062

Provider Enumeration Date	:	06/18/2009
Last Update Date	:	06/18/2009

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