Provider Demographics
NPI:1093727026
Name:CAPARRA INTERNAL MEDICINE SERVICE GROUP PSC
Entity Type:Organization
Organization Name:CAPARRA INTERNAL MEDICINE SERVICE GROUP PSC
Other - Org Name:CAPARRA INTERNAL MEDICINE SERVICE GROUP PSC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTA- FONTANET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-801-4025
Mailing Address - Street 1:390 CALLE GARDENIA
Mailing Address - Street 2:LA PONDEROSA
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745-2201
Mailing Address - Country:US
Mailing Address - Phone:787-809-4025
Mailing Address - Fax:787-809-3424
Practice Address - Street 1:390 CALLE GARDENIA
Practice Address - Street 2:LA PONDEROSA
Practice Address - City:RIO GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00745-2201
Practice Address - Country:US
Practice Address - Phone:787-809-4025
Practice Address - Fax:787-809-3424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13484207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH57293Medicare UPIN