Provider Demographics
NPI:1588113310
Name:MI MEDICO PRIMARIO INC
Entity type:Organization
Organization Name:MI MEDICO PRIMARIO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:ROSARIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-863-4058
Mailing Address - Street 1:PO BOX 1008
Mailing Address - Street 2:
Mailing Address - City:FAJARDO
Mailing Address - State:PR
Mailing Address - Zip Code:00738
Mailing Address - Country:US
Mailing Address - Phone:787-863-4058
Mailing Address - Fax:
Practice Address - Street 1:410 AVE GENERAL VALERO
Practice Address - Street 2:SUITE 307
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738-3949
Practice Address - Country:US
Practice Address - Phone:787-863-4058
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17633261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRFZ408AOtherMEDICARE PTAN