Provider Demographics
NPI:1225206071
Name:PHYSICIAN PREMIER MEDICAL GROUP, PSC
Entity Type:Organization
Organization Name:PHYSICIAN PREMIER MEDICAL GROUP, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTE
Authorized Official - Prefix:
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-736-2252
Mailing Address - Street 1:# 7 NORTE
Mailing Address - Street 2:CALLE MUNOZ RIVERA
Mailing Address - City:SAN LORENZO
Mailing Address - State:PR
Mailing Address - Zip Code:00754
Mailing Address - Country:US
Mailing Address - Phone:787-736-2252
Mailing Address - Fax:
Practice Address - Street 1:# 7 NORTE
Practice Address - Street 2:CALLE MUNOZ RIVERA
Practice Address - City:SAN LORENZO
Practice Address - State:PR
Practice Address - Zip Code:00754
Practice Address - Country:US
Practice Address - Phone:787-736-2252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization