Provider Demographics
NPI:1871633933
Name:MUNICIPIO DE ISABELA
Entity Type:Organization
Organization Name:MUNICIPIO DE ISABELA
Other - Org Name:CENTRO ISABELINO MEDICINA AVANZADA - RX
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRADOR
Authorized Official - Prefix:
Authorized Official - First Name:GISSELLE
Authorized Official - Middle Name:K
Authorized Official - Last Name:VAN DERDYS
Authorized Official - Suffix:
Authorized Official - Credentials:MHSA
Authorized Official - Phone:787-830-2705
Mailing Address - Street 1:P.O. BOX 737
Mailing Address - Street 2:
Mailing Address - City:ISABELA
Mailing Address - State:PR
Mailing Address - Zip Code:00662
Mailing Address - Country:US
Mailing Address - Phone:787-830-2705
Mailing Address - Fax:787-830-0465
Practice Address - Street 1:AVE. AGUSTIN R. CALERO.
Practice Address - Street 2:KM 1.1. ISABELA
Practice Address - City:ISABELA
Practice Address - State:PR
Practice Address - Zip Code:00662
Practice Address - Country:US
Practice Address - Phone:787-830-2705
Practice Address - Fax:787-830-0465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRTRX261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRHF575AMedicare UPIN