Provider Demographics
NPI:1336101112
Name:ROOSEVELT PEDIATRIC GROUP
Entity Type:Organization
Organization Name:ROOSEVELT PEDIATRIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:PEREZ-DAVILA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-753-1097
Mailing Address - Street 1:576 CALLE CESAR GONZALEZ
Mailing Address - Street 2:SUITE 404
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918-3756
Mailing Address - Country:US
Mailing Address - Phone:787-753-1097
Mailing Address - Fax:787-764-3927
Practice Address - Street 1:576 CALLE CESAR GONZALEZ
Practice Address - Street 2:SUITE 404
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3756
Practice Address - Country:US
Practice Address - Phone:787-753-1097
Practice Address - Fax:787-764-3927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-05
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty