MEDICARE: PRIME RADIOLOGY OF WINTER HAVEN, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	ME62144	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ME62144	OTHER	FL	LICENSE

General Provider Information

NPI Number	:	1669864658
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIME RADIOLOGY OF WINTER HAVEN, INC.

Provider Business Mailing Address
First Line	:	7524 CYPRESS GARDENS BLVD
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33884-3200
Country	:	US
Telephone Number	:	850-624-5666
Fax Number	:	321-348-5777

Provider Business Practice Location Address
First Line	:	7524 CYPRESS GARDENS BLVD
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33884-3200
Country	:	US
Telephone Number	:	850-624-5666
Fax Number	:	321-348-5777

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	THOMAS BROWN
Credential	:	M.D
Telephone Number	:	850-624-5666

Provider Enumeration Date	:	02/27/2015
Last Update Date	:	04/19/2017

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