Provider Demographics
NPI:1942559869
Name:PRIME RADIOLOGY
Entity Type:Organization
Organization Name:PRIME RADIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BONG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:630-430-5085
Mailing Address - Street 1:3000 N. OCEAN DRIVE APT#34B
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33404
Mailing Address - Country:US
Mailing Address - Phone:630-430-5085
Mailing Address - Fax:
Practice Address - Street 1:1700 SE HILLMORE DRIVE
Practice Address - Street 2:
Practice Address - City:PORT ST. LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952
Practice Address - Country:US
Practice Address - Phone:772-335-9600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 110582085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS016496019OtherMEDICARE PTAN
NCNC0317A334OtherMEDICARE PTAN
TX8L14039OtherMEDICARE PTAN
TX8L24510OtherMEDICARE PTAN
MO114630005OtherMEDICARE PTAN
TX8L24508OtherMEDICARE PTAN
NCNC0317A427OtherMEDICARE PTAN
MD229515YFP0OtherMEDICARE PTAN
TXTXB137170OtherMEDICARE PTAN
1881800621OtherINDIVIDUAL NPI
GA2021303296OtherMEDICARE PTAN
NCMC03179974OtherMEDICARE PTAN
TX8L24509OtherMEDICARE PTAN