Provider Demographics
NPI:1659551158
Name:SAN GERARDO MEDICAL CENTER CSP
Entity Type:Organization
Organization Name:SAN GERARDO MEDICAL CENTER CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALDO
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-897-0560
Mailing Address - Street 1:PO BOX 916
Mailing Address - Street 2:
Mailing Address - City:LARES
Mailing Address - State:PR
Mailing Address - Zip Code:00669-0916
Mailing Address - Country:US
Mailing Address - Phone:787-897-0560
Mailing Address - Fax:
Practice Address - Street 1:CARR 129 KM 27.3 BO PUEBLO
Practice Address - Street 2:
Practice Address - City:LARES
Practice Address - State:PR
Practice Address - Zip Code:00669
Practice Address - Country:US
Practice Address - Phone:787-897-0560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR10885OtherTRIPLE- S