1700131604 NPI number — PRIME CARE PHYSICIANS, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700131604 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:
Provider Other Organization Name Type Code:
6
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:
1700131604
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2012
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:
518-435-2740
Provider Business Mailing Address Fax Number:
518-649-4025

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
279 TROY RD
Provider Second Line Business Practice Location Address:
ROUTE 4
Provider Business Practice Location Address City Name:
RENSSELAER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12144-9499
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-880-6300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/17/2012

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".




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