1295017010 NPI number — PREMIER NUCLEAR MEDICINE CSP

Table of content: (NPI 1295017010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295017010 NPI number — PREMIER NUCLEAR MEDICINE CSP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER NUCLEAR MEDICINE CSP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295017010
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
URBANIZACION SANTA ROSA
Provider Second Line Business Mailing Address:
CALLE 9 BLQ 17 NO 17
Provider Business Mailing Address City Name:
BAYAMON
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00959-6606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-402-0100
Provider Business Mailing Address Fax Number:
787-294-6099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HOSPITAL RYDER MEMORIAL
Provider Second Line Business Practice Location Address:
355 CALLE FONT MARTELO
Provider Business Practice Location Address City Name:
HUMACAO
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00791-3249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-850-2012
Provider Business Practice Location Address Fax Number:
787-850-2012
Provider Enumeration Date:
09/19/2011

Additional Information

Authorized Official

Authorized Official Last Name:
ACEVEDO
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
787-402-0100

Provider Taxonomy Codes

  • Taxonomy code: 207UN0902X , with the licence number:  10641 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: FC340A . This is a "MEDICARE PTAN" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".




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