MEDICARE: MODERN RADIOLOGY, PSC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	RX4816	PR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RX4816	OTHER	PR	PROVIDER LICENSE NUMBER
2	1306804752	OTHER	PR	NPI

General Provider Information

NPI Number	:	1750645107
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN RADIOLOGY, PSC

Provider Business Mailing Address
First Line	:	P O BOX 7346
Second Line	:
City	:	PONCE
State	:	PR
Zip	:	00732-7346
Country	:	US
Telephone Number	:	787-709-4337
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 AVE FELISA RINCON
Second Line	:	72 VISTAS SHOPPING VILLAGE
City	:	SAN JUAN
State	:	PR
Zip	:	00926-6088
Country	:	US
Telephone Number	:	787-709-4337
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GAMALIER BERMUDEZ RUIZ
Credential	:	MD
Telephone Number	:	787-848-8834

Provider Enumeration Date	:	06/30/2012
Last Update Date	:	06/30/2012

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