1811262447 NPI number — PRIME CARE PHYSICIANS, PLLC

Table of content: (NPI 1811262447)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811262447 NPI number — PRIME CARE PHYSICIANS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIME CARE PHYSICIANS, PLLC
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:
NORTHEAST ADVANCED IMAGING
Provider Other Organization Name Type Code:
3
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:
1811262447
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 ATRIUM DR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12205-1441
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-435-2704
Provider Business Mailing Address Fax Number:
518-458-2610

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 NORTHERN BLVD
Provider Second Line Business Practice Location Address:
MEDICAL IMAGING DEPARTMENT
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12204-1004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-471-3283
Provider Business Practice Location Address Fax Number:
518-471-3064
Provider Enumeration Date:
03/15/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WHALEN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
DIRECTOR OF ADMINISTRATION
Authorized Official Telephone Number:
518-435-2704

Provider Taxonomy Codes

  • Taxonomy code: 2085N0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0904X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 02616571 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1011152 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".