Provider Demographics
NPI:1922457928
Name:ADVANCE PEDIATRIC
Entity type:Organization
Organization Name:ADVANCE PEDIATRIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-888-2302
Mailing Address - Street 1:A3 AVE PEREZ ANDINO
Mailing Address - Street 2:VILLAS DE RIO GRANDE
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745
Mailing Address - Country:US
Mailing Address - Phone:787-888-2302
Mailing Address - Fax:
Practice Address - Street 1:AVE PEREZ ANDINO A3
Practice Address - Street 2:VILLAS DE RIO GRANDE
Practice Address - City:RIO GRANDE
Practice Address - State:PUERTO RICO
Practice Address - Zip Code:00745
Practice Address - Country:UG
Practice Address - Phone:787-888-2302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR010759261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR010759OtherLICENSE NUMBER
PRIH541AOtherPTAN NUMBER