Healthcare Provider Details

I. General information

NPI: 1588028393
Provider Name (Legal Business Name): PRIME DIGITAL RADIOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 W ALARY LN
CORRALES NM
87048-8396
US

IV. Provider business mailing address

9 W ALARY LN
CORRALES NM
87048-8396
US

V. Phone/Fax

Practice location:
  • Phone: 505-353-1062
  • Fax:
Mailing address:
  • Phone: 505-353-1062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2000-76
License Number StateNM

VIII. Authorized Official

Name: DR. KIERNAN MORROW
Title or Position: OWNER
Credential: M.D.
Phone: 505-353-1062