Provider Demographics
NPI:1508072208
Name:BASIC MEDICAL GROUP,INC
Entity Type:Organization
Organization Name:BASIC MEDICAL GROUP,INC
Other - Org Name:BASIC MEDICAL GROUP,INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENTE
Authorized Official - Prefix:DR
Authorized Official - First Name:LUZ
Authorized Official - Middle Name:C
Authorized Official - Last Name:CASTELLANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-751-8758
Mailing Address - Street 1:AVENIDA MUNOZ RIVERA
Mailing Address - Street 2:PARADA 31
Mailing Address - City:HATO REY
Mailing Address - State:PR
Mailing Address - Zip Code:00917
Mailing Address - Country:US
Mailing Address - Phone:787-751-8757
Mailing Address - Fax:787-751-8757
Practice Address - Street 1:AVENIDA MUNOZ RIVERA
Practice Address - Street 2:PARADA 31
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00917
Practice Address - Country:US
Practice Address - Phone:787-751-8757
Practice Address - Fax:787-751-8757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR5830191251OtherCLASSICARE
PR7321OtherAMERICAN HEALTH
PR7321OtherAMERICAN HEALTH
PR=========OtherMCSCOMERCIAL
PR143=========OtherGLOBAL