Provider Demographics
NPI:1639449572
Name:GRUPO RADIOLOGICO DR. MANUEL QUEVEDO BAEZ
Entity Type:Organization
Organization Name:GRUPO RADIOLOGICO DR. MANUEL QUEVEDO BAEZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE SUB DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARITZA
Authorized Official - Middle Name:
Authorized Official - Last Name:VEGA DE JESUS
Authorized Official - Suffix:
Authorized Official - Credentials:MBH HCM
Authorized Official - Phone:787-480-3841
Mailing Address - Street 1:CALLE SAN AGUSTIN #359 PUERTA DE TIERRA
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00901
Mailing Address - Country:US
Mailing Address - Phone:787-480-3841
Mailing Address - Fax:787-977-0544
Practice Address - Street 1:CALLE SAN AGUSTIN #359 PUERTA DE TIERRA
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00901
Practice Address - Country:US
Practice Address - Phone:787-480-3841
Practice Address - Fax:787-977-0544
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CDT DR.MANUEL QUEVEDO BAEZ
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR400015Medicare PIN