MEDICARE: CT RADIOLOGY COMPLEX, LLC

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number State
1	207RC0000X	Cardiovascular Disease Physician	PR
2	207U00000X	Nuclear Medicine Physician
3	2085B0100X	Body Imaging Physician
4	2085D0003X	Diagnostic Neuroimaging (Radiology) Physician
5	2085N0700X	Neuroradiology Physician
6	2085N0904X	Nuclear Radiology Physician
7	2085U0001X	Diagnostic Ultrasound Physician
8	2471C3401X	Computed Tomography Radiologic Technologist
9	2471C3402X	Radiography Radiologic Technologist
10	2471M1202X	Magnetic Resonance Imaging Radiologic Technologist
11	2471M2300X	Mammography Radiologic Technologist
12	2471N0900X	Nuclear Medicine Technology Radiologic Technologist
13	2471V0105X	Vascular Sonography Radiologic Technologist
14	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center
15	2085R0202X	Diagnostic Radiology Physician

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0080100	OTHER	PR	MEDICARE

NPI Number	:	1558356493
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CT RADIOLOGY COMPLEX, LLC

Provider Business Mailing Address
First Line	:	PO BOX 602727
Second Line	:
City	:	BAYAMON
State	:	PR
Zip	:	00960-6037
Country	:	US
Telephone Number	:	787-780-9069
Fax Number	:	787-625-2626

Provider Business Practice Location Address
First Line	:	1815 RD 2
Second Line	:	CT RADIOLOGY BUILDING
City	:	BAYAMON
State	:	PR
Zip	:	00959-7279
Country	:	US
Telephone Number	:	787-780-9069
Fax Number	:	787-780-2121

Authorized Official
Title or Position	:	FINANCE VP
Name	:	MS. NORISELLE Z. RIVERA - POL
Credential	:
Telephone Number	:	787-621-3724

Provider Enumeration Date	:	09/16/2005
Last Update Date	:	09/04/2020