Provider Demographics
NPI:1043512197
Name:PUERTO RICO MEDICAL GROUP
Entity type:Organization
Organization Name:PUERTO RICO MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:LUZARDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-725-4548
Mailing Address - Street 1:PO BOX 9023558
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00902-3558
Mailing Address - Country:US
Mailing Address - Phone:787-725-4548
Mailing Address - Fax:787-721-0279
Practice Address - Street 1:405 CALLE SAN FRANCISCO
Practice Address - Street 2:PISO 2 OFICINA 2-C
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00901-1772
Practice Address - Country:US
Practice Address - Phone:787-725-4548
Practice Address - Fax:787-721-0279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0082909Medicare UPIN