Provider Demographics
NPI:1508994864
Name:PONCE DIAGNOSTIC RADIOLOGY CENTER CSP
Entity Type:Organization
Organization Name:PONCE DIAGNOSTIC RADIOLOGY CENTER CSP
Other - Org Name:SOCIEDAD RADIOLOGICA DEL CARIBE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERDECIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-843-9320
Mailing Address - Street 1:PO BOX 801143
Mailing Address - Street 2:
Mailing Address - City:COTO LAUREL
Mailing Address - State:PR
Mailing Address - Zip Code:00780-1143
Mailing Address - Country:US
Mailing Address - Phone:787-843-9320
Mailing Address - Fax:787-843-9320
Practice Address - Street 1:2435 AVE LAS AMERICAS HOSP DR PILA
Practice Address - Street 2:RADILOGY DEPARTMENT
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00733
Practice Address - Country:US
Practice Address - Phone:787-843-9320
Practice Address - Fax:787-843-9320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR114242085R0202X
PR114422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C77738Medicare UPIN
C79712Medicare UPIN
8 3845Medicare ID - Type Unspecified