Provider Demographics
NPI:1821066648
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 1:1320 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:2006-03-08
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR0200X, 261QR0208X, 293D00000X
MI24834335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
No293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E02504OtherBCBS OF MICHIGAN
MI114483540Medicaid
MI0E02504OtherBCBS OF MICHIGAN
MI0N21180Medicare ID - Type UnspecifiedIDTF
MI0P19480Medicare ID - Type UnspecifiedPORT XRAY PROF COMPONENT
MI0N23230Medicare ID - Type UnspecifiedPORTABLE XRAY PROVIDER