Provider Demographics
NPI:1124125356
Name:SAN GERARDO IMAGING CENTER, INC.
Entity type:Organization
Organization Name:SAN GERARDO IMAGING CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTA
Authorized Official - Prefix:MRS
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-897-0353
Mailing Address - Street 1:PO BOX 916
Mailing Address - Street 2:
Mailing Address - City:LARES
Mailing Address - State:PR
Mailing Address - Zip Code:00669
Mailing Address - Country:US
Mailing Address - Phone:787-897-0353
Mailing Address - Fax:787-897-0353
Practice Address - Street 1:CARR 129 KM 273 BO PUEBLO
Practice Address - Street 2:
Practice Address - City:LARES
Practice Address - State:PR
Practice Address - Zip Code:00669
Practice Address - Country:US
Practice Address - Phone:787-897-0353
Practice Address - Fax:787-897-0353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0084981Medicare ID - Type Unspecified