Provider Demographics
NPI:1477797686
Name:MATERNAL FETAL MEDICINE & GINECOLOGY CENTER
Entity Type:Organization
Organization Name:MATERNAL FETAL MEDICINE & GINECOLOGY CENTER
Other - Org Name:PCS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ADA
Authorized Official - Middle Name:I
Authorized Official - Last Name:GRACIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-982-0088
Mailing Address - Street 1:CALLE DEL PARQUE 607A
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00909
Mailing Address - Country:UM
Mailing Address - Phone:787-982-0088
Mailing Address - Fax:787-982-0091
Practice Address - Street 1:607A CALLE DEL PARQUE
Practice Address - Street 2:SUITE 1
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00909-2307
Practice Address - Country:US
Practice Address - Phone:787-982-0088
Practice Address - Fax:787-982-0091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-01
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10753207SG0201X, 207VM0101X
PR8973207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)Group - Multi-Specialty
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRE65769Medicare UPIN