Provider Demographics
NPI:1972726156
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:313-656-2151
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:2007-04-10
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI248342085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114483540Medicaid
MIJG006327OtherDR GOLDSMITH
MIAM010635OtherDR MAY
MIG14289Medicare UPIN
MIP19480002Medicare ID - Type UnspecifiedDR MAY
MI114483540Medicaid
GAP00295061Medicare ID - Type UnspecifiedRR MC DR GOLDSMITH
MIN2118006Medicare ID - Type UnspecifiedDR GOLDSMITH
MIN21180005Medicare ID - Type UnspecifiedDR MAY
MIF19395Medicare UPIN
MI114483531Medicare ID - Type UnspecifiedDR MAY