Basic Information
| Provider Information | |||||||||
| NPI: | 1699309161 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ONCOLOGY & BODY IMAGING PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 435 | ||||||||
| Address2: | |||||||||
| City: | ADJUNTAS | ||||||||
| State: | PR | ||||||||
| PostalCode: | 006010435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7876304735 | ||||||||
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| Practice Location | |||||||||
| Address1: | 735 AVE PONCE DE LEON | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009175022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7877582000 | ||||||||
| FaxNumber: | 7877717927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2020 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | BALLESTER ORTIZ | ||||||||
| AuthorizedOfficialFirstName: | GORY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7876304735 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.