MEDICARE: PRIME HEALTHCARE IOD

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	332900000X	Non-Pharmacy Dispensing Site

General Provider Information

NPI Number	:	1710870696
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIME HEALTHCARE IOD

Provider Business Mailing Address
First Line	:	6 NORTHWESTERN DR STE 101
Second Line	:
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-3416
Country	:	US
Telephone Number	:	860-580-5656
Fax Number	:	860-580-5799

Provider Business Practice Location Address
First Line	:	6 NORTHWESTERN DR STE 101
Second Line	:
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-3416
Country	:	US
Telephone Number	:	860-580-5656
Fax Number	:	860-580-5799

Authorized Official
Title or Position	:	DIRECTOR OF CODING AND COMPLIANCE
Name	:	SERENA ANN KIMBALL
Credential	:
Telephone Number	:	860-263-0256

Provider Enumeration Date	:	05/30/2025
Last Update Date	:	05/30/2025

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