1922457928 NPI number — ADVANCE PEDIATRIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922457928 NPI number — ADVANCE PEDIATRIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCE PEDIATRIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922457928
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
A3 AVE PEREZ ANDINO
Provider Second Line Business Mailing Address:
VILLAS DE RIO GRANDE
Provider Business Mailing Address City Name:
RIO GRANDE
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-888-2302
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
AVE PEREZ ANDINO A3
Provider Second Line Business Practice Location Address:
VILLAS DE RIO GRANDE
Provider Business Practice Location Address City Name:
RIO GRANDE
Provider Business Practice Location Address State Name:
PUERTO RICO
Provider Business Practice Location Address Postal Code:
00745
Provider Business Practice Location Address Country Code:
UG
Provider Business Practice Location Address Telephone Number:
787-888-2302
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MARTINEZ SANTIAGO
Authorized Official First Name:
GLENDA
Authorized Official Middle Name:
Authorized Official Title or Position:
PEDIATRIC
Authorized Official Telephone Number:
787-888-2302

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  010759 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010759 . This is a "LICENSE NUMBER" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".
  • Identifier: IH541A . This is a "PTAN NUMBER" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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