=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124503115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BERMUDEZ RUIZ IMAGING,PSC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2018
-----------------------------------------------------
Last Update Date | 09/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9176 CALLE MARINA
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00717-1582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-553-0620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9176 CALLE MARINA
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00717-1582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-553-0620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASISTENTE ADMINITRATIVO
-----------------------------------------------------
Name | LUIS O RAMOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-553-0620
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------