Provider Demographics
NPI:1205548815
Name:PREMIUM MEDICAL GROUP PSC
Entity type:Organization
Organization Name:PREMIUM MEDICAL GROUP PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGARDO
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:VARGAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-639-4908
Mailing Address - Street 1:CARRETERA 129, KM 1.0 AV. SAN LUIS
Mailing Address - Street 2:
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00613
Mailing Address - Country:US
Mailing Address - Phone:787-650-7272
Mailing Address - Fax:
Practice Address - Street 1:CARRETERA 129, KM 1.0 AV. SAN LUIS
Practice Address - Street 2:
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00613
Practice Address - Country:US
Practice Address - Phone:787-650-7272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty