Provider Demographics
NPI:1699722439
Name:G4 MEDICAL OF PUERTO RICO, INC
Entity type:Organization
Organization Name:G4 MEDICAL OF PUERTO RICO, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:MARINA
Authorized Official - Last Name:MORADI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-830-6210
Mailing Address - Street 1:28 CALLE CORONEL
Mailing Address - Street 2:COTTO LLANADAS
Mailing Address - City:ISABELA
Mailing Address - State:PR
Mailing Address - Zip Code:00662-4800
Mailing Address - Country:US
Mailing Address - Phone:787-830-6210
Mailing Address - Fax:787-830-6215
Practice Address - Street 1:28 CALLE CORONEL
Practice Address - Street 2:COTTO LLANADAS
Practice Address - City:ISABELA
Practice Address - State:PR
Practice Address - Zip Code:00662-4800
Practice Address - Country:US
Practice Address - Phone:787-830-6210
Practice Address - Fax:787-830-6215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR5915580001Medicare NSC