1679832729 NPI number — PRIME MEDICAL CLINIC, PLC

Table of content: (NPI 1679832729)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679832729 NPI number — PRIME MEDICAL CLINIC, PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIME MEDICAL CLINIC, PLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679832729
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5150 N 16TH ST
Provider Second Line Business Mailing Address:
SUITE B232
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85016-3925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-840-3584
Provider Business Mailing Address Fax Number:
602-957-2184

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3104 E INDIAN SCHOOL RD
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85016-6889
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-840-3584
Provider Business Practice Location Address Fax Number:
602-957-2184
Provider Enumeration Date:
05/10/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SCHINE
Authorized Official First Name:
PATRIC
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
602-840-3584

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP1483 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 729130 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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