Provider Demographics
NPI:1679646061
Name:GROUPO MEDICO DOMINICANO PLLC
Entity Type:Organization
Organization Name:GROUPO MEDICO DOMINICANO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVERAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-928-3900
Mailing Address - Street 1:629 W 185TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-3102
Mailing Address - Country:US
Mailing Address - Phone:212-928-3900
Mailing Address - Fax:212-795-0470
Practice Address - Street 1:629 W 185TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-3102
Practice Address - Country:US
Practice Address - Phone:212-928-3900
Practice Address - Fax:212-795-0470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03178503Medicaid
NYWWQ661Medicare PIN