Provider Demographics
NPI:1437192051
Name:EASTERN ADVANCED MEDICAL GROUP
Entity Type:Organization
Organization Name:EASTERN ADVANCED MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSITRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-285-0655
Mailing Address - Street 1:CALLE DUFRESNE NO. 59 W
Mailing Address - Street 2:
Mailing Address - City:HUMACAO
Mailing Address - State:PR
Mailing Address - Zip Code:00791-3609
Mailing Address - Country:US
Mailing Address - Phone:787-285-0655
Mailing Address - Fax:
Practice Address - Street 1:CALLE DUFRESNE NO. 59 W
Practice Address - Street 2:
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791-3609
Practice Address - Country:US
Practice Address - Phone:787-285-0655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty