Provider Demographics
NPI:1801334883
Name:NORTH SHORE MEDICAL GROUP LLC
Entity type:Organization
Organization Name:NORTH SHORE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:RODRIGUEZ - PORTELA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-345-9682
Mailing Address - Street 1:781 CALLE ARRAYADO
Mailing Address - Street 2:URB. SAN DEMETRIO
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00693
Mailing Address - Country:US
Mailing Address - Phone:787-858-3550
Mailing Address - Fax:787-855-3339
Practice Address - Street 1:39 CARR 2
Practice Address - Street 2:HOSPITAL WILMA N VAZQUEZ SUITE 101
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693-4824
Practice Address - Country:US
Practice Address - Phone:787-858-3550
Practice Address - Fax:787-855-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-09
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14001208D00000X
PR16634207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PREE510AMedicare Oscar/Certification