Provider Demographics
NPI:1821061938
Name:PROFESSIONAL SONOCARDIOGRAPHIC IMAGING
Entity Type:Organization
Organization Name:PROFESSIONAL SONOCARDIOGRAPHIC IMAGING
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:313-656-2151
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 1:1320 WILKINS ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4802
Practice Address - Country:US
Practice Address - Phone:313-656-2151
Practice Address - Fax:313-656-2152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-09
Last Update Date:2011-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114483504Medicaid
MI114483522Medicaid
MI470000653OtherRAILROAD MEDICARE
MI0E01 184OtherBC/BS
MI114483522Medicaid