Provider Demographics
NPI:1316979701
Name:PRIME DIAGNOSTICS
Entity type:Organization
Organization Name:PRIME DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SUJWALA
Authorized Official - Middle Name:PUTTAGUNTA
Authorized Official - Last Name:BOPPUDI
Authorized Official - Suffix:
Authorized Official - Credentials:MS, MBA
Authorized Official - Phone:301-459-5200
Mailing Address - Street 1:4451 BROOKFIELD CORPORATE DR STE 205
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-1693
Mailing Address - Country:US
Mailing Address - Phone:703-378-8100
Mailing Address - Fax:703-378-8101
Practice Address - Street 1:4300 FORBES BLVD
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-4314
Practice Address - Country:US
Practice Address - Phone:301-459-5200
Practice Address - Fax:301-459-5400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21-D1057808291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010400635Medicaid
DC039531500Medicaid
MD412222400Medicaid
CL8625Medicare PIN