Basic Information
| Provider Information | |||||||||
| NPI: | 1346831179 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MGE RADIOLOGY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 48 AVE MUNOZ RIVERA APT 2807 | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009181661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7875054136 | ||||||||
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| Practice Location | |||||||||
| Address1: | 107 CALLE COMERCIO | ||||||||
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| City: | JUANA DIAZ | ||||||||
| State: | PR | ||||||||
| PostalCode: | 007951646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7878373285 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2021 | ||||||||
| LastUpdateDate: | 02/03/2021 | ||||||||
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| AuthorizedOfficialLastName: | ECHEVARRIA QUINTANA | ||||||||
| AuthorizedOfficialFirstName: | MIGUEL | ||||||||
| AuthorizedOfficialMiddleName: | GABRIEL | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 7875054136 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1174839179 | 05 | PR | MEDICAID |