Provider Demographics
NPI:1255319703
Name:PEDIATRIX MEDICAL GROUP OF PUERTO RICO, P.S.C
Entity Type:Organization
Organization Name:PEDIATRIX MEDICAL GROUP OF PUERTO RICO, P.S.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:VELAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-999-0753
Mailing Address - Street 1:PO BOX 11913
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00922-1913
Mailing Address - Country:US
Mailing Address - Phone:787-999-0753
Mailing Address - Fax:787-535-1509
Practice Address - Street 1:1451 AVE ASHFORD
Practice Address - Street 2:CONDADO
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907-1511
Practice Address - Country:US
Practice Address - Phone:787-722-6004
Practice Address - Fax:787-722-6003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-05
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR207PE0004X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency MedicineGroup - Single Specialty
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR=========OtherTAX ID