Healthcare Provider Details

I. General information

NPI: 1952425100
Provider Name (Legal Business Name): MODERN RADIOLOGY,PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 01/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9176 CALLE MARINA
PONCE PR
00717-1582
US

IV. Provider business mailing address

PO BOX 7346
PONCE PR
00732-7346
US

V. Phone/Fax

Practice location:
  • Phone: 787-843-1625
  • Fax: 787-843-1723
Mailing address:
  • Phone: 787-841-1949
  • Fax: 787-812-0565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number4816
License Number StatePR

VIII. Authorized Official

Name: DR. GAMALIER BERMUDEZ-RUIZ
Title or Position: PRESIDENT
Credential: MD
Phone: 787-843-1625