Provider Demographics
NPI:1295017010
Name:PREMIER NUCLEAR MEDICINE CSP
Entity Type:Organization
Organization Name:PREMIER NUCLEAR MEDICINE CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:ACEVEDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-402-0100
Mailing Address - Street 1:URBANIZACION SANTA ROSA
Mailing Address - Street 2:CALLE 9 BLQ 17 NO 17
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00959-6606
Mailing Address - Country:US
Mailing Address - Phone:787-402-0100
Mailing Address - Fax:787-294-6099
Practice Address - Street 1:HOSPITAL RYDER MEMORIAL
Practice Address - Street 2:355 CALLE FONT MARTELO
Practice Address - City:HUMACAO
Practice Address - State:PR
Practice Address - Zip Code:00791-3249
Practice Address - Country:US
Practice Address - Phone:787-850-2012
Practice Address - Fax:787-850-2012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-19
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR10641207UN0902X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRFC340AOtherMEDICARE PTAN