Provider Demographics
NPI:1063519122
Name:PONCE ADVANCE MEDICAL GROUP
Entity type:Organization
Organization Name:PONCE ADVANCE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASISTENTE ADMINISTRATIVA
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAMARYS
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-813-2324
Mailing Address - Street 1:PMB 282
Mailing Address - Street 2:1575 MUNOZ RIVERA AVE.
Mailing Address - City:PONCE
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00717
Mailing Address - Country:UM
Mailing Address - Phone:787-813-2324
Mailing Address - Fax:787-841-3908
Practice Address - Street 1:AVENIDA HOSTOS
Practice Address - Street 2:ESQUINA POWER # 1266
Practice Address - City:PONCE
Practice Address - State:PUERTO RICO
Practice Address - Zip Code:00730
Practice Address - Country:UM
Practice Address - Phone:787-813-2324
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR07-B-2318261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR10517Medicaid