Provider Demographics
NPI:1770105900
Name:PENRAD IMAGING LLC
Entity type:Organization
Organization Name:PENRAD IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RADIOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BERGESON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-593-1799
Mailing Address - Street 1:1390 KELLY JOHNSON BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3908
Mailing Address - Country:US
Mailing Address - Phone:719-593-1799
Mailing Address - Fax:719-265-3794
Practice Address - Street 1:4925 N NEVADA AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-8600
Practice Address - Country:US
Practice Address - Phone:719-593-1799
Practice Address - Fax:719-265-3794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-11
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology