Provider Demographics
NPI:1669684734
Name:PRIME DIAGNOSTIC IMAGING CORP.
Entity Type:Organization
Organization Name:PRIME DIAGNOSTIC IMAGING CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-648-8860
Mailing Address - Street 1:3075 VETERANS MEMORIAL HWY
Mailing Address - Street 2:SUITE 160
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7667
Mailing Address - Country:US
Mailing Address - Phone:631-648-8860
Mailing Address - Fax:631-648-8859
Practice Address - Street 1:3075 VETERANS MEMORIAL HWY
Practice Address - Street 2:SUITE 160
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-7667
Practice Address - Country:US
Practice Address - Phone:631-648-8860
Practice Address - Fax:631-648-8859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171063261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology