Provider Demographics
NPI:1760427744
Name:SUPRAMED
Entity Type:Organization
Organization Name:SUPRAMED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARBALLIDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-759-6265
Mailing Address - Street 1:ROAD #19 GARDEN HILL PLAZA #1353
Mailing Address - Street 2:PMB #228
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966
Mailing Address - Country:US
Mailing Address - Phone:787-759-6265
Mailing Address - Fax:
Practice Address - Street 1:DE DIEGO AVENUE #359 ALTOS
Practice Address - Street 2:#319 ALTOS
Practice Address - City:RIO PIEDRAS
Practice Address - State:PR
Practice Address - Zip Code:00923
Practice Address - Country:US
Practice Address - Phone:787-759-6265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRTCAMB-1083416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0059282Medicare ID - Type Unspecified