Healthcare Provider Details

I. General information

NPI: 1821066648
Provider Name (Legal Business Name): PSI RADIOLOGICAL SERVICE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 05/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 WILKINS ST
DETROIT MI
48207-4802
US

IV. Provider business mailing address

547 E JEFFERSON AVE
DETROIT MI
48226-4324
US

V. Phone/Fax

Practice location:
  • Phone: 313-656-2151
  • Fax: 313-656-2152
Mailing address:
  • Phone: 313-962-2133
  • Fax: 313-962-2134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License Number24834
License Number StateMI

VIII. Authorized Official

Name: DR. VICTOR COLLADO
Title or Position: RADIOLOGIST
Credential: M.D., PHD
Phone: 313-962-2133