Provider Demographics
NPI:1841432143
Name:HYDE PARK MEDICAL GROUP PSC
Entity type:Organization
Organization Name:HYDE PARK MEDICAL GROUP PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-250-6425
Mailing Address - Street 1:370 ANDREAS COURT
Mailing Address - Street 2:10 TH ST, BOX 90
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00976-7804
Mailing Address - Country:US
Mailing Address - Phone:787-250-6425
Mailing Address - Fax:
Practice Address - Street 1:212 CALLE LAS MARIAS
Practice Address - Street 2:HYDE PARK
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00927-4213
Practice Address - Country:US
Practice Address - Phone:787-250-6425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15965261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care