Provider Demographics
NPI:1710196209
Name:PEDIAMED
Entity Type:Organization
Organization Name:PEDIAMED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN CARLOS
Authorized Official - Middle Name:DEL RIO
Authorized Official - Last Name:ROURE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-730-1166
Mailing Address - Street 1:CALLE BEGONIA 162
Mailing Address - Street 2:CIUDAD JARDIN 2
Mailing Address - City:TOA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CARRETERA #172
Practice Address - Street 2:HOSPITAL SAN JUAN BAUTISTA
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00726
Practice Address - Country:US
Practice Address - Phone:787-730-1166
Practice Address - Fax:787-730-1166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-10-11
Provider Licenses
StateLicense IDTaxonomies
PR10285261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty