MEDICARE: HYDE PARK MEDICAL GROUP 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	261QP2300X	Primary Care Clinic/Center	15965	PR

General Provider Information

NPI Number	:	1841432143
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HYDE PARK MEDICAL GROUP PSC

Provider Business Mailing Address
First Line	:	370 ANDREAS COURT
Second Line	:	10 TH ST, BOX 90
City	:	TRUJILLO ALTO
State	:	PR
Zip	:	00976-7804
Country	:	US
Telephone Number	:	787-250-6425
Fax Number	:

Provider Business Practice Location Address
First Line	:	212 CALLE LAS MARIAS
Second Line	:	HYDE PARK
City	:	SAN JUAN
State	:	PR
Zip	:	00927-4213
Country	:	US
Telephone Number	:	787-250-6425
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. EDGARDO GONZALEZ
Credential	:	MD
Telephone Number	:	787-250-6425

Provider Enumeration Date	:	04/01/2009
Last Update Date	:	04/01/2009

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