MEDICARE: PSI RADIOLOGIST GROUP, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085U0001X	Diagnostic Ultrasound Physician
2	2085B0100X	Body Imaging Physician
3	2085D0003X	Diagnostic Neuroimaging (Radiology) Physician
4	2085N0700X	Neuroradiology Physician	4301024834	MI
5	2085N0904X	Nuclear Radiology Physician
6	2085P0229X	Pediatric Radiology Physician
7	2085R0204X	Vascular & Interventional Radiology Physician
8	2085R0202X	Diagnostic Radiology Physician

General Provider Information

NPI Number	:	1326359910
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSI RADIOLOGIST GROUP, PC

Provider Business Mailing Address
First Line	:	547 E JEFFERSON AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48226-4324
Country	:	US
Telephone Number	:	313-962-2133
Fax Number	:	313-962-2134

Provider Business Practice Location Address
First Line	:	561 E JEFFERSON AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48226-4324
Country	:	US
Telephone Number	:	313-964-9072
Fax Number	:	313-964-9407

Authorized Official
Title or Position	:	RADIOLOGIST
Name	:	DR. VICTOR COLLADO
Credential	:	M.D. PHD
Telephone Number	:	313-964-9072

Provider Enumeration Date	:	06/29/2010
Last Update Date	:	06/17/2011

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