Healthcare Provider Details

I. General information

NPI: 1295017010
Provider Name (Legal Business Name): PREMIER NUCLEAR MEDICINE CSP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2011
Last Update Date: 06/01/2020
Certification Date: 06/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HOSPITAL RYDER MEMORIAL 355 CALLE FONT MARTELO
HUMACAO PR
00791-3249
US

IV. Provider business mailing address

URBANIZACION SANTA ROSA CALLE 9 BLQ 17 NO 17
BAYAMON PR
00959-6606
US

V. Phone/Fax

Practice location:
  • Phone: 787-850-2012
  • Fax: 787-850-2012
Mailing address:
  • Phone: 787-402-0100
  • Fax: 787-294-6099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number10641
License Number StatePR

VIII. Authorized Official

Name: MARIA E ACEVEDO
Title or Position: PRESIDENT
Credential: MD
Phone: 787-402-0100