MEDICARE: GRUPO MEDICO DEL NORESTE

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

General Provider Information

NPI Number	:	1639164262
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRUPO MEDICO DEL NORESTE

Provider Business Mailing Address
First Line	:	41A CALLE ORQUIDEA
Second Line	:	LOIZA VALLEY
City	:	CANOVANAS
State	:	PR
Zip	:	00729-3540
Country	:	US
Telephone Number	:	787-256-5659
Fax Number	:	787-256-5659

Provider Business Practice Location Address
First Line	:	41A CALLE ORQUIDEA
Second Line	:	LOIZA VALLEY
City	:	CANOVANAS
State	:	PR
Zip	:	00729-3540
Country	:	US
Telephone Number	:	787-256-5659
Fax Number	:	787-256-5659

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. FERNANDO BORDET
Credential	:	M.D
Telephone Number	:	787-256-5659

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	10/02/2012

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