Organization
PRIME RADIOLOGY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JEFFREY S BONG D.O. (PRESIDENT)
(630) 430-5085
Entity
Organization
Contact information
Practice address
1700 SE HILLMORE DRIVE, PORT ST. LUCIE, FL 34952
(772) 335-9600
Mailing address
3000 N. OCEAN DRIVE APT#34B, WEST PALM BEACH, FL 33404
(630) 430-5085
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
OS 11058
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
016496019
MEDICARE PTAN
KS
01
—
114630005
MEDICARE PTAN
MO
01
—
1881800621
INDIVIDUAL NPI
—
01
—
2021303296
MEDICARE PTAN
GA
01
—
229515YFP0
MEDICARE PTAN
MD
01
—
8L14039
MEDICARE PTAN
TX
01
—
8L24508
MEDICARE PTAN
TX
01
—
8L24509
MEDICARE PTAN
TX
01
—
8L24510
MEDICARE PTAN
TX
01
—
MC03179974
MEDICARE PTAN
NC
01
—
NC0317A334
MEDICARE PTAN
NC
01
—
NC0317A427
MEDICARE PTAN
NC
01
—
TXB137170
MEDICARE PTAN
TX
Enumeration date
09/06/2012
Last updated
09/06/2012
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