Provider Demographics
NPI:1780951566
Name:GRUPO MEDICO CENTRO MEDICINA ESPECIALIZADA
Entity type:Organization
Organization Name:GRUPO MEDICO CENTRO MEDICINA ESPECIALIZADA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLAZO
Authorized Official - Suffix:
Authorized Official - Credentials:BS, PE
Authorized Official - Phone:787-466-6828
Mailing Address - Street 1:BARCELO #12, ESQ. 173
Mailing Address - Street 2:
Mailing Address - City:CIDRA
Mailing Address - State:PR
Mailing Address - Zip Code:00739-0000
Mailing Address - Country:US
Mailing Address - Phone:787-739-2054
Mailing Address - Fax:787-739-5525
Practice Address - Street 1:BARCELO #12, ESQ. 173
Practice Address - Street 2:
Practice Address - City:CIDRA
Practice Address - State:PR
Practice Address - Zip Code:00739-0000
Practice Address - Country:US
Practice Address - Phone:787-739-2054
Practice Address - Fax:787-739-5525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR122261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRFB142AMedicare UPIN