Provider Demographics
NPI:1174791347
Name:GRUPO MEDICO CLASICO
Entity type:Organization
Organization Name:GRUPO MEDICO CLASICO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEVES-ROMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-585-8888
Mailing Address - Street 1:PMB 157 BOX 2500
Mailing Address - Street 2:
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PR
Mailing Address - Zip Code:00987
Mailing Address - Country:US
Mailing Address - Phone:787-585-8888
Mailing Address - Fax:787-888-8887
Practice Address - Street 1:L2 CALLE 6
Practice Address - Street 2:VILLAS DE RIO GRANDE
Practice Address - City:RIO GRANDE
Practice Address - State:PR
Practice Address - Zip Code:00745-2825
Practice Address - Country:US
Practice Address - Phone:787-585-8888
Practice Address - Fax:787-888-8887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C77626Medicare UPIN