Provider Demographics
NPI:1306421714
Name:BAYAMON PODIATRIC CLINIC PSC
Entity type:Organization
Organization Name:BAYAMON PODIATRIC CLINIC PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:787-565-4886
Mailing Address - Street 1:P12 AVE MAGNOLIA
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00956-2608
Mailing Address - Country:US
Mailing Address - Phone:787-785-9282
Mailing Address - Fax:
Practice Address - Street 1:P12 CALLE MAGNOLIA
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00956-2608
Practice Address - Country:US
Practice Address - Phone:787-785-9282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-17
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty