Provider Demographics
NPI:1780652594
Name:SOUTH WESTERN RADIOLOGY SERVICES PSC
Entity Type:Organization
Organization Name:SOUTH WESTERN RADIOLOGY SERVICES PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-807-0900
Mailing Address - Street 1:PO BOX 1498
Mailing Address - Street 2:
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00694-1498
Mailing Address - Country:US
Mailing Address - Phone:787-807-0900
Mailing Address - Fax:787-855-2729
Practice Address - Street 1:D10 CALLE 2
Practice Address - Street 2:URB. VILLA REAL
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693-4611
Practice Address - Country:US
Practice Address - Phone:787-807-0900
Practice Address - Fax:787-855-2729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-08
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR05-265261QM1200X, 261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR008-4912OtherMEDICARE PTAN