Provider Demographics
NPI:1770915894
Name:SM IMAGING PSC
Entity type:Organization
Organization Name:SM IMAGING PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT SMI
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:L
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-621-3700
Mailing Address - Street 1:100 GRAND BOULEVARD PASEO , 112 PMB 412
Mailing Address - Street 2:CALLE ADAMS
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926
Mailing Address - Country:US
Mailing Address - Phone:787-414-1250
Mailing Address - Fax:
Practice Address - Street 1:CALLE HERNANDEZ CARRION, URB. ATENAS
Practice Address - Street 2:MANATI MEDICAL CENTER
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00974
Practice Address - Country:US
Practice Address - Phone:787-621-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-31
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12064261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0089572Medicare PIN