Provider Demographics
NPI:1326398314
Name:GRUPO MEDICO CDT DR. MANUEL QUEVEDO BAEZ
Entity Type:Organization
Organization Name:GRUPO MEDICO CDT DR. MANUEL QUEVEDO BAEZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUB DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARITZA
Authorized Official - Middle Name:VEGA
Authorized Official - Last Name:DE JESUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-444-9295
Mailing Address - Street 1:PO BOX 21405
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00928-1405
Mailing Address - Country:US
Mailing Address - Phone:787-480-3876
Mailing Address - Fax:787-977-8401
Practice Address - Street 1:SAN AGUSTIN # 359
Practice Address - Street 2:PUERTA DE TIERRA
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00901-2938
Practice Address - Country:US
Practice Address - Phone:787-480-3876
Practice Address - Fax:787-977-8401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRLIC 2261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR400015Medicare PIN