1942559869 NPI number — PRIME RADIOLOGY

Table of content: (NPI 1942559869)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942559869 NPI number — PRIME RADIOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIME RADIOLOGY
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:
1942559869
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3000 N. OCEAN DRIVE APT#34B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST PALM BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-430-5085
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 SE HILLMORE DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ST. LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34952
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-335-9600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/06/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BONG
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
630-430-5085

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  OS 11058 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 016496019 . This is a "MEDICARE PTAN" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: NC0317A334 . This is a "MEDICARE PTAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8L14039 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8L24510 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 114630005 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 8L24508 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: NC0317A427 . This is a "MEDICARE PTAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 229515YFP0 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: TXB137170 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1881800621 . This is a "INDIVIDUAL NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2021303296 . This is a "MEDICARE PTAN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: MC03179974 . This is a "MEDICARE PTAN" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8L24509 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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