Provider Demographics
NPI:1962974527
Name:PRIME MEDICAL IMAGING, LLC
Entity type:Organization
Organization Name:PRIME MEDICAL IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSSOMAKHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-929-5482
Mailing Address - Street 1:8930 WAUKEGAN RD STE 130
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-2132
Mailing Address - Country:US
Mailing Address - Phone:847-929-5460
Mailing Address - Fax:847-929-5461
Practice Address - Street 1:10260 191ST ST
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8801
Practice Address - Country:US
Practice Address - Phone:708-215-3899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-20
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty