Provider Demographics
NPI:1669864658
Name:PRIME RADIOLOGY OF WINTER HAVEN, INC.
Entity Type:Organization
Organization Name:PRIME RADIOLOGY OF WINTER HAVEN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-624-5666
Mailing Address - Street 1:7524 CYPRESS GARDENS BLVD
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33884-3200
Mailing Address - Country:US
Mailing Address - Phone:850-624-5666
Mailing Address - Fax:321-348-5777
Practice Address - Street 1:7524 CYPRESS GARDENS BLVD
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884-3200
Practice Address - Country:US
Practice Address - Phone:850-624-5666
Practice Address - Fax:321-348-5777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-27
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME621442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME62144OtherLICENSE