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General NPI Number Information
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NPI Number | 1942559869
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Entity Type | Organization
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Legal Business Name | PRIME RADIOLOGY
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Dates
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Enumeration Date | 09/06/2012
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Last Update Date | 09/06/2012
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Provider Practice Location Address
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Address Line | 1700 SE HILLMORE DRIVE
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City | PORT ST. LUCIE
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State | FL
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Zip | 34952
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Country | US
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Telephone | 772-335-9600
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Fax |
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Provider Business Mailing Address
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Address Line | 3000 N. OCEAN DRIVE APT#34B
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City | WEST PALM BEACH
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State | FL
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Zip | 33404
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Country | US
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Telephone | 630-430-5085
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JEFFREY S BONG
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Credential | D.O.
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Telephone | 630-430-5085
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | OS 11058
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License Number State | FL
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