Provider Demographics
NPI:1407270606
Name:INTERNAL MEDICINE CANOVANAS GROUP CORP.
Entity Type:Organization
Organization Name:INTERNAL MEDICINE CANOVANAS GROUP CORP.
Other - Org Name:CENTRO CUIDADO PREVENTIVIO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:
Authorized Official - Last Name:MERINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-256-0848
Mailing Address - Street 1:PO BOX 20000
Mailing Address - Street 2:PMB 121
Mailing Address - City:CANOVANAS
Mailing Address - State:PR
Mailing Address - Zip Code:00729
Mailing Address - Country:US
Mailing Address - Phone:787-256-0848
Mailing Address - Fax:787-256-2990
Practice Address - Street 1:48 CALLE ORQUIDEA
Practice Address - Street 2:URB LOIZA VALLEY
Practice Address - City:CANOVANAS
Practice Address - State:PR
Practice Address - Zip Code:00729-3596
Practice Address - Country:US
Practice Address - Phone:787-256-0848
Practice Address - Fax:787-256-2990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRHQ871AOtherMEDICARE PTAN