Healthcare Provider Details

I. General information

NPI: 1265755730
Provider Name (Legal Business Name): MODERN RADIOLOGY PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2010
Last Update Date: 03/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CALLE 25 DE JULIO # 72
YAUCO PR
00698-3604
US

IV. Provider business mailing address

PO BOX 7346
PONCE PR
00732-7346
US

V. Phone/Fax

Practice location:
  • Phone: 787-856-4262
  • Fax: 787-267-3120
Mailing address:
  • Phone: 787-856-4262
  • Fax: 787-267-3120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License Number4816
License Number StatePR

VIII. Authorized Official

Name: DR. GAMALIER BERMUDEZ-RUIZ
Title or Position: PRESIDENT
Credential: MD
Phone: 787-856-4262