Provider Demographics
NPI:1043381080
Name:JERRDAM MEDICAL, CSP
Entity Type:Organization
Organization Name:JERRDAM MEDICAL, CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTE
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUIZ ROMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-775-2545
Mailing Address - Street 1:PMB 409 PO BOX 194000
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00919-4000
Mailing Address - Country:US
Mailing Address - Phone:787-775-2545
Mailing Address - Fax:
Practice Address - Street 1:CALLE 21 U 3#5
Practice Address - Street 2:LAS LOMAS
Practice Address - City:RIO PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00921
Practice Address - Country:US
Practice Address - Phone:787-775-2545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR87945Medicare ID - Type Unspecified