Provider Demographics
NPI:1528046075
Name:PEDIATRIX MEDICAL GROUP, S.P.
Entity Type:Organization
Organization Name:PEDIATRIX MEDICAL GROUP, S.P.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT ASSOCIATE
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHINEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-999-0753
Mailing Address - Street 1:PO BOX 11913
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00922-1913
Mailing Address - Country:US
Mailing Address - Phone:787-999-0753
Mailing Address - Fax:787-999-0789
Practice Address - Street 1:6 CALLE 1 STE 202
Practice Address - Street 2:METRO OFFICE PARK
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00968-0032
Practice Address - Country:US
Practice Address - Phone:787-999-0753
Practice Address - Fax:787-999-0789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-05
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR207PP0204X, 2080N0001X, 2080P0203X, 2080P0210X, 2084N0402X
2080P0008X, 2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Multi-Specialty
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency MedicineGroup - Multi-Specialty
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental DisabilitiesGroup - Multi-Specialty
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Multi-Specialty
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-OncologyGroup - Multi-Specialty
No2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric NephrologyGroup - Multi-Specialty
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child NeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1528046075OtherTAX ID
PR1528046075OtherTAX ID