Healthcare Provider Details

I. General information

NPI: 1376767426
Provider Name (Legal Business Name): GUAM X-RAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 GOV CARLOS G CAMACHO RD GUAM MEDICAL PLAZA, SUITE 210
TAMUNING GU
96913
US

IV. Provider business mailing address

633 GOVERNOR CARLOS G. CAMACHO ROAD GUAM MEDICAL PLAZA, SUITE 210
TAMUNING GU
96913-3194
US

V. Phone/Fax

Practice location:
  • Phone: 671-649-1001
  • Fax: 671-649-1002
Mailing address:
  • Phone: 671-649-1001
  • Fax: 671-649-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. NATHANIEL BENJAMIN BERG
Title or Position: OWNER
Credential: M.D.
Phone: 671-649-1001