Provider Demographics
NPI:1588769715
Name:DIAGNOSTIC RADIOLOGY GROUP PRACTICE
Entity type:Organization
Organization Name:DIAGNOSTIC RADIOLOGY GROUP PRACTICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRENDALY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSARIO JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-761-8383
Mailing Address - Street 1:138 AVE WINSTON CHURCHILL
Mailing Address - Street 2:MCS250
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-6013
Mailing Address - Country:US
Mailing Address - Phone:787-761-8383
Mailing Address - Fax:787-292-8260
Practice Address - Street 1:138 AVE WINSTON CHURCHILL
Practice Address - Street 2:MCS250
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00926-6013
Practice Address - Country:US
Practice Address - Phone:787-761-8383
Practice Address - Fax:787-292-8260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR84969Medicare ID - Type UnspecifiedDIAGNOSTIC RADIOLOGY GROU