Provider Demographics
NPI:1457674939
Name:MODERN RADIOLOGY ,PSC
Entity Type:Organization
Organization Name:MODERN RADIOLOGY ,PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GAMALIER
Authorized Official - Middle Name:
Authorized Official - Last Name:BERMUDEZ-RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-843-1625
Mailing Address - Street 1:PO BOX 7346
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00732-7346
Mailing Address - Country:US
Mailing Address - Phone:787-843-1625
Mailing Address - Fax:787-259-1117
Practice Address - Street 1:TORRE MEDICA SAN CRISTOBAL 5TA AVE OFICINA 109
Practice Address - Street 2:
Practice Address - City:COTO LAUREL
Practice Address - State:PR
Practice Address - Zip Code:00780
Practice Address - Country:US
Practice Address - Phone:787-843-1625
Practice Address - Fax:787-259-1117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4816261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0026322Medicare PIN