Provider Demographics
NPI:1841227386
Name:PERTH AMBOY MEDICAL
Entity Type:Organization
Organization Name:PERTH AMBOY MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:VINCENTY
Authorized Official - Suffix:
Authorized Official - Credentials:AAOP
Authorized Official - Phone:787-280-1612
Mailing Address - Street 1:6 ANDRES MENDEZ LICIAGA
Mailing Address - Street 2:
Mailing Address - City:SAN SEBASTIAN
Mailing Address - State:PR
Mailing Address - Zip Code:00685
Mailing Address - Country:US
Mailing Address - Phone:787-280-1612
Mailing Address - Fax:787-280-1613
Practice Address - Street 1:6 ANDRES MENDEZ LICIAGA
Practice Address - Street 2:
Practice Address - City:SAN SEBASTIAN
Practice Address - State:PR
Practice Address - Zip Code:00685
Practice Address - Country:US
Practice Address - Phone:787-280-1612
Practice Address - Fax:787-280-1613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4916770001Medicare NSC