=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508994864
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PONCE DIAGNOSTIC RADIOLOGY CENTER CSP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2007
-----------------------------------------------------
Last Update Date | 08/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2435 AVE LAS AMERICAS HOSP DR PILA RADILOGY DEPARTMENT
-----------------------------------------------------
City | PONCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-843-9320
-----------------------------------------------------
Fax | 787-843-9320
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 801143
-----------------------------------------------------
City | COTO LAUREL
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00780-1143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-843-9320
-----------------------------------------------------
Fax | 787-843-9320
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | VICTOR A BERDECIA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 787-843-9320
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 11442
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 11424
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------