Provider Demographics
NPI:1508945635
Name:PSI RADIOLOGICAL SERVICE, INC
Entity Type:Organization
Organization Name:PSI RADIOLOGICAL SERVICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RADIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLADO
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:313-962-2133
Mailing Address - Street 1:547 E JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-4324
Mailing Address - Country:US
Mailing Address - Phone:313-962-2133
Mailing Address - Fax:313-962-2134
Practice Address - Street 1:8529 E 8 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-3067
Practice Address - Country:US
Practice Address - Phone:586-619-7025
Practice Address - Fax:586-619-7267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2011-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI24834261QM1300X, 261QR0200X, 261QR0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H228030OtherBCBS CROSSOVER
MI114483540Medicaid
GAP00295061Medicare ID - Type UnspecifiedRR MEDICARE DR. GOLDSMITH
MI114483540Medicaid
GADE4760Medicare ID - Type UnspecifiedRR MEDICARE PROF COMP
MI0P19480Medicare ID - Type UnspecifiedPROF COMP PORTABLE X-RAY
MIN19480001Medicare ID - Type UnspecifiedDR. J. GOLDSMITH X-RAY PR