Provider Demographics
NPI:1346502630
Name:MDM GROUP
Entity Type:Organization
Organization Name:MDM GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-721-0274
Mailing Address - Street 1:PO BOX 19718
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00910-1718
Mailing Address - Country:US
Mailing Address - Phone:787-721-0274
Mailing Address - Fax:787-757-8969
Practice Address - Street 1:1225 AVE PONCE DE LEON
Practice Address - Street 2:VIG TOWER SUITE 801
Practice Address - City:SANTURCE
Practice Address - State:PR
Practice Address - Zip Code:00907-3907
Practice Address - Country:US
Practice Address - Phone:787-721-0274
Practice Address - Fax:787-757-8969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1386714251171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty