Provider Demographics
NPI:1720533870
Name:PRIME RADIOLOGY OF MAITLAND INC
Entity Type:Organization
Organization Name:PRIME RADIOLOGY OF MAITLAND INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
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:863-535-5544
Mailing Address - Street 1:7960 FOREST CITY RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32810-2938
Mailing Address - Country:US
Mailing Address - Phone:863-535-5544
Mailing Address - Fax:321-348-5777
Practice Address - Street 1:7960 FOREST CITY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32810-2938
Practice Address - Country:US
Practice Address - Phone:863-535-5544
Practice Address - Fax:321-348-5777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-18
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME621442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty