Provider Demographics
NPI:1174823090
Name:SANTA ISABEL MEDICAL GROUP
Entity Type:Organization
Organization Name:SANTA ISABEL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:D
Authorized Official - Last Name:QUILES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-845-6211
Mailing Address - Street 1:PO BOX 645
Mailing Address - Street 2:
Mailing Address - City:SANTA ISABEL
Mailing Address - State:PR
Mailing Address - Zip Code:00757-0645
Mailing Address - Country:US
Mailing Address - Phone:787-845-6211
Mailing Address - Fax:787-845-2925
Practice Address - Street 1:CALLE LUIS MUNOZ RIVERA
Practice Address - Street 2:NUMERO 54
Practice Address - City:SANTA ISABEL
Practice Address - State:PR
Practice Address - Zip Code:00757-0000
Practice Address - Country:US
Practice Address - Phone:787-845-6211
Practice Address - Fax:787-845-2925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7665173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR7665OtherLICENSE