Provider Demographics
NPI:1679625131
Name:SAN PABLO PHYSICAL MEDICINE PSC
Entity Type:Organization
Organization Name:SAN PABLO PHYSICAL MEDICINE PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IVELISSE
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-786-2469
Mailing Address - Street 1:EL MIRADOR
Mailing Address - Street 2:# J10 6TH STREET
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-748-6277
Mailing Address - Fax:
Practice Address - Street 1:TORRE SAN PABLO # 68 SANTA CRUZ ST.
Practice Address - Street 2:SUITE 603
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961-7035
Practice Address - Country:US
Practice Address - Phone:787-786-2469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR82563Medicare UPIN